The
NGWRC provides education, advocacy and support for veterans
suffering from the complexities of modern warfare;

we
specialize in Gulf War Illness with additional focus in Traumatic
Brain Injury and Post-Traumatic Stress Disorder.

NGWRC
Self-Help Guide

A
Guide toToday’s Toxic
Wars

Information
and Support for those involved in and transformed by today’s
wars.

Updated
June, 2013

Distribution and Disclaimer

The
contents of this guide are for informational purposes only and
neither the National Gulf War Resource Center, Inc., nor its
principals assume responsibility for the accuracy or veracity of the
information contained herein. This guide is distributed freely to
veterans, families, civilians, service providers and others
interested in helping those who are ill, injured, or disabled due to
the Persian Gulf War, Operation Desert Storm, Operation Iraqi
Freedom, Operation Enduring Freedom, and other combat operations of
the US Military. Please feel free to copy and distribute this Guide
for educational, counseling, self-help, and scholarly purposes. We
request only that proper credit be given. Any other use requires
the written authorization of the National Gulf War Resource Center,
Inc.

This updated Guide is the result
of months of reviewing changes in regulations and science regarding
Gulf War Illness and other conditions affecting veterans who served
our country from 1989 to the present day, and turning that
information into a reference veterans and their advocates can use.
It is a core resource in our work to improve medical treatment and
quality of like for these injured veterans.

The NGWRC thanks the
following individuals and groups for their contributions to this
guide:

The
National Veterans Legal Services Program funded and developed the
original Guide.

Dr. Tim Rot works in the field
of PTSD, and he reviewed the PSTD chapter of this Guide. I would
like to thank him for giving of his free time to help our veterans.

Col. (Ret) George Webb, U.S.
Army, was the Executive Director of the Kansas Commission of Veteran
Affairs for 5 years. He worked closely with the project that
produced a world renowned study on gulf war illness in 2001 commonly
called ‘The Kansas Study’ by Lea Steele PhD.

Cpt. David Winnett, jr. U.S.M.C.
(Ret) is the past president and mentor to the Executive Director.
He helped identify important research, reviewed drafts of this
Guide, and helped in more ways than can be recounted here. He has
been on the CDMRP for a number of years to advance our cause.

William Ankenbauer, jr. is a
retired DAV service officer and adviser to the NGWRC. He provided
invaluable insight and advice on how a veteran may develop his or
her claim and work as a team with their VSO Rep. Bill worked when
DAV had their school and great National Service Officers like JM.

Ron E. Brown is the acting
president and identified much of the research referred to in this
Guide.

Lisa Cornett helped review and
proofread this guide, among her many contributions to NGWRC.

Tonia Goertz took time out of
her her profession, writing for a living, to advise us in the work
of making this Guide useful and readable for as many veterans as
possible.

Brent Casey reviewed the drafts
and contributed ideas.

Paul Davidson edited and
organized this edition of the guide.

Finally, we thank the past
leaders and members of the NGWRC who wrote previous editions of this
guide and performed the advocacy work which allows many veterans to
receive care and benefits today that they could not get a few years
ago.

-James
Bunker, Executive Director

INTRODUCTION

The
NGWRC

Veterans
and non-veterans run the National Gulf War Resource Center (NGWRC).
We help veterans affected by the 'invisible' injuries most common in
the current conflict period, from 1989 to the present day. These
injuries include Gulf War Illness (GWI), Traumatic Brain Injury
(TBI), and Post-Traumatic Stress Disorder (PTSD).

We
are among the most successful Veterans' Organizations in the United
States advocating for veterans affected by GWI. We formed shortly
after the Persian Gulf War of 1991. Our work has been critical in
establishing the rights, treatments, and benefits which these
veterans have access to now. Our work is far from done. GWI is
still poorly understood and incurable. While no longer in complete
denial, the VA and the Department of Defense (DOD) misuse GWI
research funds and ignore recommendations from the scientific
community that may lead to better treatment. Claims for VA benefits
related to GWI are still difficult to prove.

Since
Operation Desert Storm, later conflicts, including Operation
Enduring Freedom and Operation Iraqi Freedom, have brought many new
claims for other 'invisible' injuries, TBI and PTSD, as well as a
reduced frequency of new Gulf War Illness cases among recent
veterans deployed in and near Iraq. We expanded the original guide
to include these conditions. In the last 20 years, we distributed
over 200,000 copies of
this guide; this 11th edition is a key resource to
helping recent combat veterans.

The
term 'Gulf War Veteran' refers to any a veteran who served in
Southwest Asia during Operations, Desert Shield/Storm, Iraqi
Freedom, Enduring Freedom or any other operations with dates from
August 1990 until the present day. We work with veterans who have
served since 1989 until today no matter the Area of Operation.

Purpose
of this Guide

When
people are injured on-the-job in civilian work, their employers must
pay for related medical treatment and provide compensation. If you
are a veteran with injuries or disabilities incurred in the line of
duty, you have earned the right to medical treatment and
compensation for conditions connected to your service. The VA
provides this care and compensation after you are discharged.

Common
war injuries like Gulf War Illness (GWI)/Chronic Multisymptom
Illness (CMI) and Post-Traumatic Stress Disorder (PTSD) are
difficult to diagnose. GWI was not recognized by the scientific and
medical community for several years after the events which first
caused it.

If
you are an ill or injured veteran this is your Guide
to understanding GWI [including Undiagnosed Illness (UI) and
medically unexplained CMI's], ALS, Traumatic Brain Injury (TBI), and
PTSD. This guide focuses on what you need to know in order to file
a claim with the Department of Veterans Affairs (VA) for disability
compensation benefits you have earned as a result of your injury in
service.

Information
on technical research and legislative developments was moved to the
appendices in order to focus on what you need to file a claim or get
help and support. If you are reading a guide more than one year
old, please visit our website, www.ngwrc.org,
to see if it has been updated, and to learn of any important
developments in research and benefits.

When
you are injured in the line of duty, you earn treatment and
compensation for that injury. However, you still have to prove that
your injury occurred, is currently disabling, and is connected to
your service. Among veterans, as in the civilian world, a small
number of individuals make false claims while others make honest but
erroneous claims. On the VA side, some adjudicators do not
understand injuries like PTSD and GWI/CMI, and a few actively
promote misinformation about them. These factors combine to create
a complex claims adjudication system which places a heavy burden on
veterans. Read on to understand how to build your claim with the
facts and increase the chance that you will be treated fairly.

No
matter what condition or injury you live with as a result of your
service, you have a burden of proof to meet before the VA will grant
you the benefits you have earned.

The
basic burden of proof carries two components.

Medical evidence
of a current physical or mental disability, AND

Evidence of a relationship between your disability and an
injury, disease, or event in military service. Medical records or
medical opinions are usually required to establish this
relationship.

In
some cases, this is a high burden of proof. However, for most of
the illnesses and injuries discussed in this guide, the VA has
additional rules which ease the burden of proof for many veterans.
The rules are different for each condition, so read each chapter
carefully if it applies to you.

This
guide focuses on 'less visible' and 'invisible' conditions which
affect veterans. In many cases, you and the people in your daily
life will see symptoms, signs, or changes in behavior weeks, months,
or years before you receive a diagnosis. These may begin while you
are still in the military. Developing a written record of the
changes, as observed by yourself and those around you, is a critical
step in preparing your claim. Develop a record that goes back to
the time changed first began if possible. These statements may also
help your doctor provide a more accurate diagnosis and measure the
extent to which it is disabling.

Here
is an example of the importance of lay testimony related to Chronic
Fatigue Syndrome (CFS) – imagine yourself as a veteran with
severe CFS going to see your doctor. During your few minutes with
the doctor, you are fully responsive. You appear normal, fit, and
able-bodied. However, your boss at work knows that you call in sick
more than anyone else, you need more and longer 'smoke breaks', and
you tire out long before the day ends, dragging yourself out of the
work place at the end of the day. You are highly motivated and
productive, but it is clear that your output is compromised from
what it would be if you were healthy. Your partner at home sees
that you barely move from the time you get home until the time you
have to leave for work the next day, and that you rest all weekend,
no longer able to do yard work, go shopping, or go out for social
activities like you used to. In this case, lay testimony can prove
you are much more disabled than the initial doctor's report will
suggest. That affects whether you receive the compensation you
deserve or get a much smaller benefit instead.

As
you read this guide, highlight the symptoms you have. Create a list
of symptoms to share with your doctor. For each symptom, list the
start date, how often per [day, week, month, or year] you experience
it, and how bad it gets. Every detail you take time to spell out
helps you make your case.

Have
your loved ones keep a note book on you that describes your health
problems and their effects on your life. The notes of your loved
ones can be used to write a narrative which supports your claim.

Remember
to ask loved ones, co-workers, and friends you served with to write
down any changes in your behavior in addition to other symptoms, and
ask them to mention when those changes began. They may be more
aware of the changes than you are. Evidence of changes in behavior
can be important to help diagnose conditions affecting many
post-1990 veterans.

Keeping
track of your symptoms like this will not only help you with your
doctor, but help you write up your statement for your claim. The
notes of your daily write-up can also become a part of your claim to
help in setting your rating amount.

Statements
in Support of Claim

Statements
in Support of Claim are Lay evidence presented in the format which
the VA requires in order to consider them as part of your case.

You
should write a statement in support of claim [VA form 21-4138] for
each condition you are claiming. You may also have family members,
co-workers, friends, and people you served with fill out this form.
Download the form at
http://www.va.gov/vaforms/form_detail.asp?FormNo=21-4138.

Get
statements from those that you served with during the war if there
are parts to your claim that will need these statements. Find those
you served with after the war and people who have known you since
your discharge. If they saw evidence directly, or if you complained
to them, they can write statements about your different symptoms, or
about how your behavior changed. While these statements cannot
diagnose your problems, they can attest to what they observe
directly, or they can describe a conversation in which you
complained of symptoms or how those symptoms affected you.

Be
sure each statement is signed and dated. Make sure it has a a line
which states: to the best of my knowledge, this statement is true
(VA form 21-4138 already includes this). Take a copy of all
supporting statements to your Veterans Service Organization
Representative (VSO Rep). Make sure you keep the originals.

The perspective of
a doctor

Doctors are professionals. Their job is to find out what is going
with your body today and determine the best treatments to help you
with that. As you work with them, focus on what they need to know
to help you now.

When you are giving a doctor information about your medical
condition, focus on information related directly to it. What are
the symptoms you have now? How severe are they? How do they affect
your work and other daily activities? When did they begin? Have
they gotten worse or better over time? Does this doctor have full
access to your medical records, or do you need to obtain copies of
some records and bring them to him or her?

If you go beyond this and begin focusing on specific events that
you think caused the condition, or on how you believe you were
wrongly ignored or improperly treated in the past, you may end up
with a referral for mental health treatment instead of the medical
care and diagnoses you need to manage your disability and support
your claim for compensation from the VA.

Most of the types of claims listed in this guide are presumptive
for most of the veterans that file them. If you are part of the
qualified group, you are not going to need an 'as likely as not'
medical opinion to prove that your injury is connected to your
service. You don't need to prove the connection, and trying to do
so can be a distraction to providing you with the best medical care.

In the event that you are the exception, that you do need a medical
opinion linking your diagnosis or symptoms to your military service,
focus on what your doctor needs to know in order to write that
letter to support you. In such a case, yes, the doctor will need to
know about the event which you believe caused the disability. That
is the only extra thing he or she needs to know directly from you.
The rest of what your doctor needs are copies of – or links to
– scientific and medical research, journal articles, and
reports or opinions from other doctors, which support your 'at least
as likely as not' position.

If you need an 'as likely as not' letter, try to say just one or two
sentences about your date and location of exposure and the onset of
your symptoms, then give your doctor a copy of your DD-214 and SMR's
that relate directly to those. Bring copies of the relevant pages
of an Institute of Medicine report, medical journal article, or
other peer-reviewed information from the medical and medical science
communities which supports your position. If the doctor's letter
requires that you establish onset of symptoms by a certain date,
include written statements from other people about when the symptoms
manifested. Let the doctor review that so he or she may write the
letter based on medical evidence rather than your opinions.

Obtain a diagnosis
from a medical professional

You
cannot diagnose yourself with any of the conditions in this guide.
Only a doctor may do that. In the case of PTSD, which is a mental
health condition, the diagnosis must come from a psychologist or
psychiatrist. In any case, your primary care doctor may refer you
to a specialist and require testing before determining your
diagnosis.

After
getting your lay evidence together, take the information with you to
your next doctor appointment. Open up a dialogue with the doctor
assigned to you as your Primary Care Provider (PCP). Share any
chapter of this guide which applies to your claim if it is outside
your doctor's normal expertise. Your doctor needs to assess your
symptoms, and in some cases, he or she will need to order specific
tests and exams to help you meet a burden of proof. The regional VA
office which adjudicates your claim may order the same tests and
exams; however, you have a stronger claim if they have already been
done by, or at the instruction of, a doctor who you know and trust.

When
you, as a veteran, encounter difficulties at a VA medical facility
you may contact the patient advocate at that location for
assistance in resolving the problem. If that does not work you may
move up the ladder until you get the help you need. In some cases,
you may be assigned a doctor who does not understand your injury or
who is unwilling or unable to help you.

If
you have a doctor who will not work with you, the patient
advocate is there to help you get things worked out. Your
team social worker and the patient advocate can help you get a
different doctor. Do not suffer with a doctor that will not help
you.

If
you are using a Community-Based Outpatient Clinic (CBOC), you may
have to go to a VA Medical Center in order to see a different
doctor. A CBOC may not have enough flexibility or staff to change
your PCP.

Additional
medical evidence

Medical
evidence is crucial to your claim. Try to provide only medical
evidence which is relevant.

Provide
a copy of all relevant medical evidence you have from non-VA
doctors. While you may be filling out a VA 21-4142 to grant
permission to obtain medical records, the Regional Office (RO)
cannot always get the files from private doctors. Outside doctors
sometimes ask the VA to pay for making copies, and the VA will not
pay for copies. Get a copy for yourself and keep it. Make another
copy to give to the VA.

If
a civilian doctor's office asks you to pay for copies of your
medical records (as many do), let them know that you are a military
veteran and need the copies in order to apply for Veterans
Disability Benefits. Many doctors and/or their office staff will
waive their normal copy fee as an act of good will in honor of your
service. If the doctor's office offers to fax or mail your records
to the VA for you, politely decline. Tell them you plan to make a
copy for yourself first and then mail the records to the VA
personally, via certified mail, so you will have proof that the VA
received them. Tell them that the VA is notorious for losing and
misplacing records.

Go
through your service medical records if you have them. Make a copy
of the records which are relevant to your claim and include that
copy in the material for the VA.

If you have a
record showing that you cut your finger in basic training, or
anything else that does not support the claim you are filing, leave
it out of the copies you send to the VA. Making the ratings officer
try to find the needle which proves your claim is valid, in a
haystack of other records that have nothing to do with your claim,
will not help you.

Disability
Benefits Questionnaires (DBQs)

If
you use a private, non-VA doctor to help you prepare a Fully
Developed Claim (FDC), they will need to fill out Disability
Benefits Questionnaires (DBQs) related to your diagnoses and
symptoms. Only doctors may fill out a DBQ. You may download or
print the correct forms for your doctor in advance, by going here:
http://www.benefits.va.gov/COMPENSATION/dbq_disabilityexams.asp
.

The
VA may order a Compensation and Pension (C&P) examination by a
VA doctor regardless of the evidence you provide. The VA doctor
should also use DBQs as part of your C&P exam.

There
are some diagnoses for which no DBQ is available. Your private
doctor may still provide a medical opinion in support of your claim;
however they will not be able to use a DBQ in relation to that
diagnosis. In most of these cases, the VA will require you to get
an exam from one of its doctors.

Find
a Veterans Service Organization Representative (VSO Rep)

It
is always an advantage, regardless of the nature of the disorder
underlying a claim for benefits, to have an accredited veterans
service organization representative (VSO Rep) assist you in the
prosecution of a claim for VA disability compensation. These
individuals may be called a veterans service representative (VSR) or
a veterans service officer (VSO). In any case, the VA accredits
them as a VSO Rep. You should only have an accredited VSO Rep
working on your case, and you can search the database of the VA
Office of the General Counsel (OGC) to determine if a VSO Rep is
currently accredited or not at
http://www.va.gov/ogc/apps/accreditation/index.asp
.

You
may also use that link to find a VSO Rep. If you want to work with
a particular Veterans Service Organization, or with your State
Veterans Affairs office, go directly to their website to locate a
VSO Rep who works for them. In some states, there are county VSO
Reps.

All
accredited VSO Reps are familiar with veterans benefits law and
procedures, and they can provide more effective representation than
trying to handle the claim yourself. Some are volunteers, and
others are paid for by tax dollars or private donations. They may
not charge you for their services.

Keep
in touch. You should talk to your representative at least once per
month while your claim is pending. Whenever you get mail from the
VA, call your representative to make sure that he or she received a
copy (as required by VA regulations) and that you understand exactly
what it means.

Ask
questions. If you do not understand something about your claim, ask.
Part of your VSO Rep's responsibility is to ensure that you
understand the claims process.

Exercise
your judgment. Your VSO Rep is charged with acting in your best
interests. However, you are the ultimate decision maker with
respect to your claim. Your VSO Rep will tell you if he or she
disagrees with what you want to do and why. He or she can make
recommendations but must do as you instruct. The law permits VSO
Reps to resign if there are fundamental disagreements.

Insist
that your VSO Rep:

discuss
your case with you;

be
familiar with your VA claims file and all of the evidence;

be
able and willing to discuss the specific VA regulations related to
your case and what evidence is needed to prevail;

discuss
your case and what to anticipate with respect to personal hearings;

submit
a written statement to the VA before a personal hearing. He or she
should let you read the statement before it is submitted.

Although
it can be a difficult task, shop around for the best advocate. Talk
to the prospective representative; ask if there are any limits on
his or her representation. Get a feel for the person who will be
working for you before you sign a power of attorney appointing him
or her as your representative.

When
should you consider a VA accredited attorney or claims
agent?

A
VA accredited attorney or claims agent may charge you a contingency
fee, a percentage of the back benefits you are awarded when your
claim is granted, in return for representing you to the VA as you
pursue your claim. This is money out of your pocket, and VSO Reps
(no cost to you) are well qualified to represent veterans for most
claims. If you have a claim which has already been denied once, and
you are looking for highly specialized representation from someone
who can spend more time on your individual case, then you may
consider an accredited attorney or claims agent to help you pursue
your claim.

You
may need an attorney if your case is going before the Court of
Veterans Appeals or to a higher court. If your case is at the Board
of Veterans Appeals or your Regional Office, either an attorney or a
claims agent may help you with the case.

Interview
anyone you are considering. You may even ask for and contact
references before you allow them to represent you. You should find
someone who has specific expertise with claims for your type of
disability, and who has a proven track record of success. In other
respects, you should treat your attorney or claims agent as you
would treat a VSO Rep.

Prepare
and file your application for benefits

Now
it is time to file the claim, and to do so you will need to have all
your documents together.

If
you never filed a claim before, there are certain documents you
should have. They are your DD-214, your marriage certificate [and
if you are no longer married, your divorce papers], and paperwork on
your children or any other dependents. You need your DD-214 to show
when you served in the military. If your claim is rated at 30% or
higher, you will receive extra compensation for your spouse and any
children under 18 that you claim as dependents.

Gather
your Statements in Support of Claim, Medical Evidence from private
doctors, and any military records in your possession which support
your claim. Keep the original of every document for yourself, and
make a copy for the VA. There are several forms involved in
preparing and presenting your claim for disability compensation to
the VA. Your VSO Rep can help you figure out which forms are
needed, and how to get them filled out properly. You may find links
to many of the forms below.

You
should apply for benefits as soon as your claim is complete. An
incomplete claim may be denied; however, each month that passes by
without filing is a month of benefits you give up forever.

Talk
to your VSO Rep about whether you should apply for benefits other
than disability compensation. This
guide focuses on that type of claims. For an overview of all VA
benefits, go to http://benefits.va.gov/benefits/ .

If
you and your VSO Rep believe that the evidence you are presenting is
complete and no additional information is needed to grant the claim
you are seeking, you may go through the VA's Fully Developed Claims
(FDC) Program, described below, to receive a faster decision.

If
your claim is missing some records which may help your case, and you
want to VA to try to obtain those records before it makes a
decision, you should use the traditional claims process, which will
take longer to complete. In the long run, your benefits will still
go back to the date on which your application is received.

Your
VSO Rep will help you make sure all the appropriate forms and
evidence are together with your application. Once that is done, the
application may be mailed or scanned and filed electronically.

What is a Fully
Developed Claim?

The
Fully Developed Claims (FDC) Program was developed to provide a
faster decision to veterans who are able to fully prepare their own
claim for benefits. A VSO Rep will help you with this. FDC is the
fastest way of getting your compensation or pension claim processed.

To
participate, you provide all private (non-government) medical and
lay evidence which you want to be considered, attached to your
original claim. You then inform the VA that they don't need to
spend time looking for it. Participation in the FDC Program allows
for faster claims processing but preserves your right to appeal a
decision. Information is at
http://benefits.va.gov/transformation/fastclaims/
.

There
are no DBQs for the following medical examinations:
Initial Examination for Post-Traumatic Stress Disorder, Hearing Loss
and Tinnitus, Residuals of Traumatic
Brain Injury,
Cold Injury Residuals, Prisoner of War Examination Protocol, Gulf
War Medical Examination.

You
can request a copy of your service
medical records from
the National Personnel Record Center (NPRC) in St. Louis, Mo., using
a Standard Form 180, Request Pertaining to Military Records. This
form is available from your representative or any VA office. You
can also apply for a copy of your service records online
http://www.archives.gov/veterans/military-service-records/
.

The
NPRC Fire of July 1973 destroyed many Army and Air Force records of
personnel discharged between 1912 and 1964. If you were discharged
after Jan 1, 1964, or if you served in the Navy or Marines,
your records were not burned, and you should be able to obtain a
copy. Source:
http://www.archives.gov/st-louis/military-personnel/fire-1973.html
.

What
to do when you disagree with part
or all
of the VA's decision

The
first step in appealing a claim is to send your VA Regional Office
(VARO) a "Notice of Disagreement" (NOD). There is no
official NOD form. Generally, the NOD can be a written statement on
VA Form 21-4138 (Statement in Support of Claim) or a letter that
states that you disagree with the decision. Be sure to include in
your NOD the date of the decision that you disagree with, which
issues you disagree with, and that you intend to appeal those
issues. You have one year from the date of the VA’s
notice of its decision to file your NOD with your VARO. If you miss
this deadline, you can only reopen your claim based on new and
material evidence or establishing that the VA denial was the product
of clear and unmistakable error (which is very difficult to prove).
The other exception to these conditions occurs when VA regulations
regarding your disability change, as they did with PTSD in 2010. In
that case you may have the right to re-open your claim based on the
change in regulations.

You
do not help yourself if you simply dump a pile of loose records on
the VA. Organize the records and explain their significance in a
letter you and your VSO Rep prepare together. Once the VARO makes a
decision with respect to your claim, you (and your VSO Rep) will
receive a notice of that decision which explains the reasons for the
VA’s determination. Read the notice carefully and discuss it
with your representative. Your appeal should address specific
reasons why the VA should not have denied a claimed condition, why
an awarded rating is too low, or why an effective date is too late.

After the VARO
receives your NOD, you should receive a letter that acknowledges
your NOD. You will be asked whether you wish to have your appeal
sent to the Board of Veterans’ Appeals (BVA) in Washington,
D.C., or whether you wish to have your claim reviewed on a de
novo basis. The latter refers to the VA’s Decision Review
Officer (DRO) program. This is an informal appellate process within
each VARO. The DRO has the authority to reverse or modify a VA
rating board decision. We recommend that you seek DRO review before
you request a BVA appeal. The DRO process is frequently successful
and is generally faster than going straight to the BVA. If you do
not receive a better decision from the DRO, you can still appeal to
the BVA.

Once
the DRO has made a decision or has received your request for BVA
consideration, the VA will issue a “Statement of the Case”
(SOC). This document will explain the VA’s decision(s) in
detail. You have 60 days from the date of the SOC to file your
substantive appeal to the BVA on VA Form 9: http://www.va.gov/vaforms/form_detail.asp?FormNo=9.
Your appeal will be certified and forwarded to the BVA for
consideration.

You
are entitled to one copy of your entire VA claims file (or C-file)
without charge. If you have ever had any official contact with the
VA that relates to a claim for benefits, your claims file should
contain all of the service and post-service medical records that the
VA has, as well as any correspondence to or from the VA and
adjudication-related documentation.

Survivors'
Benefits

Sometimes
a veteran’s survivors, including spouses, children and
dependent parents may apply for service-connected death benefits
(Dependency and Indemnity Compensation or DIC program) or for
non-service-connected death benefits (pension program). For example,
a survivor might be able to show that a veteran with
service-connected PTSD died as a consequence of a disease that was
secondary to PTSD, e.g.,
cardiovascular disease, substance abuse (in certain cases). A VSO
Rep is able to help the survivor with this type of claim.

What
are the compensation rates?

To
find the current VA disability compensation monthly payment rates,
please go to the VA website at www.va.gov.
From the homepage, click on “Compensation”, then on
“Rate Tables”. Additional monthly payments may be
available based on the beneficiary’s number of dependents.

Filing
a claim while still active duty military

If you are currently serving on
active duty in the U.S. Military, including a mobilization of your
Reserve or Guard unit, you may apply for VA disability compensation
if both of the following are true:

You know your date of
separation, retirement, or release from active duty or mobilization

As
you enter into this process, make sure to report
everything, even the ringing in your ears. If you carried heavy loads around,
and you were sore for days afterward at least once, you should
report that, even if you feel fine now. These are only two examples
– go through every part of your anatomy, every way in which
your thoughts and emotional state have changed. If it might
possibly interfere with your work or your relationships, now or ever,
report it as a possible disability.

While this process
makes it much easier than it once was to receive the benefits you
are due as soon as you leave the military, it also makes it easier
to deny anything you forget to mention, or which you believe doesn't
matter … now.

Many disabilities
will be evident in a thorough and complete exam if you direct the
doctor to look for them. Some of them degenerate over time, causing
you pain and interfering with your ability to work. Repetitive
stress to your back, for example, may not even slow you down today.
However, it may have set in motion degradation of a disk, or created
some other issue, which will degenerate and be truly disabling in
several years. Hearing loss and many other conditions develop in
much the same way – getting worse over time.

Remember to get a
complete copy of your own Service Medical Record (SMR) before you
leave. A VA claims adjudicator may miss evidence that supports your
claim when they are reviewing your file. If you can make a copy of
the relevant information and highlight it for them, it makes your
case much easier to appeal, if you need to, than simply telling the
VA 'well, it's in there'.

Once
you have a copy of your SMR, keep it forever. If someone else needs
information from it, make a copy of what they need and give them the
copy.

Chapter II – Claims
for Gulf
War Illness
and Infectious Diseases

General
information for all CFR 38, §3.317
claims

Chapters II-V deal with claims for presumptive service-connection
for Gulf War Illness (GWI)/Chronic Multisymptom Illness(CMI)
[Persian Gulf & Iraq Veterans – CFR 38,
§3.317(a)]
and Infectious Disease Claims [Persian Gulf, Iraq & Afghanistan
Veterans – CFR 38, §3.317(c)].
Persian Gulf/Iraq claims for presumptive service connection require
that you serve in the Southwest Asia Theater (SWAT) during the time
period of 1990-current*. Afghanistan service related claims cover a
period of service from 2001 to current.

If you believe you have an infectious disease claim, most of what
you need is in Chapter V.

If you have a medically unexplained chronic multisymptom illness,
aka Gulf War Illness, whether it is diagnosed or not, you will need
to read most of this chapter. You will also need to refer to
whichever parts of Chapter III and Chapter IV are related to your
symptoms and diagnoses.

What
is Gulf War Illness and who may file a claim for it?

Gulf War Illness
(GWI) refers to a sickness first documented among veterans of
Operation Desert Shield and Operation Desert Storm in 1990-1991.
More than one in four of these veterans still experience a wide
range of unexplained symptoms, such as fatigue, pain, and problems
with digestion, for which there is no visible cause or explanation.
Most have had this condition since their deployment or soon after
it.

It took years of
strong advocacy by the veterans themselves before the much of the
medical community, including the VA, accepted GWI as a medical
disorder. Today, the exact cause remains unknown. Scientific
research proves that, whatever the cause, the disability is real and
it is likely related to military service in the Persian Gulf region.
Treatment methods and compensation ratings for this condition are
still evolving.

Scientists and
Medical Researchers now use the term medically unexplained Chronic
Multisymptom Illness (CMI) instead of Gulf War Illness (GWI). They
mean the same thing. CMI is a more inclusive term which applies to
all people affected by the disorder. Exposures present in the
Southwest Asia Theater (SWAT) of Operations greatly increased the
risk of CMI among Gulf War Veterans.

The
National Academy of Sciences (NAS) Institute of Medicine (IOM) uses
the following definition in its 2013 report: Gulf
War and Health: Treatment for Chronic Multisymptom Illness (page x in the preface):

We
defined CMI as the presence of a spectrum of chronic symptoms
experienced for six months or longer in at least two of six
categories—fatigue, mood and cognition, musculo-skeletal,
gastrointestinal, respiratory, and neurologic—that may overlap
with, but are not fully captured by, known syndromes (such as
irritable bowel syndrome, chronic fatigue syndrome, and
fibromyalgia) or other diagnoses.

That is the current
scientific definition of what we commonly call GWI. In the rest of
this guide, we will refer to definitions and symptoms based in
Federal Law and used in VA regulations and guidelines, even if they
are not updated to reflect the most recent scientific research.
When you as an Iraq or Persian Gulf veteran file a claim for
compensation related to GWI/CMI, you are filing for presumptive
service-connection of a qualifying chronic disability.

Qualifying
chronic disability,under
38CFR§3.317(a)(2)(i),
means a chronic disability resulting from any of the following or
any combination of the following:

(A)
An undiagnosed illness;

(B)
A medically unexplained chronic multisymptom illness that is defined
by a cluster of signs or symptoms,
such as

This chapter deals
with undiagnosed illness claims, the (A) in the list above.

The
VA does not recognize the term “Gulf
War Illness” as a compensable disability. It uses the term
medically
unexplained chronic multisymptom illness
(CMI) instead. The VA does compensate veterans who have it when
they file claims using the definitions it recognizes. CFR 38,
§3.317(a)
and §3.317(b)
address the CMI's commonly called Gulf War Illness.

The
VA grants presumptive service-connection to 'Persian Gulf Veterans'
for medically unexplained CMI's which are rated at least 10%
disabling, and which manifest the disabling symptoms for at least
six consecutive months before the end of 2016. It does not matter
whether the CMI is an undiagnosed illness, a diagnosis named in
§3.317(a)(2)(i)(B),
a diagnosis not specifically named but which meets the criteria, or
some combination of those. If the illness meets basic criteria, and
it occurs in a veteran who served in the 'Southwest Asia Theater',
it is Gulf War Illness, i.e. a CMI which is eligible for presumptive
service connection.

If
you have Gulf War Illness or any medically unexplained CMI, and you
meet the definition of Persian Gulf Veteran (1990-current* period of
service in Southwest Asia) you may file for disability compensation
under CFR 38, section 3.317 -
Compensation
for certain disabilities occurring in Persian Gulf veterans.

To keep it simple,
we may call this a '3.317(a) claim' in this chapter. That means the
same thing as a claim for Gulf War Illness. A '3.317(c) claim' may
apply to a claim for certain infectious diseases, covered in Chapter
V. Both CMI and infectious disease claims are '3.317 claims'.

What
is Persian Gulf War Service (1990-current*)

Only a 'Persian
Gulf Veteran' – a termwhich includes OIF, Desert Storm, and most other Iraq veterans – may file §3.317(a) claims. A Persian Gulf Veteran is any current or former member of
the United States Armed Forces who served in the Southwest Asia
Theater of Operations for at least one day between August 2, 1990
and the current date*.

*The
VA is considering an 'end date' to 'Persian Gulf War Service' of
December 18, 2011, the last day of Operation New Dawn. If this 'end
date' is eventually approved, you will need to show evidence of SWAT
service between August 2, 1990 and December 18, 2011 to gain
presumptive service-connection.

Which
military operations are included?

This
is not a complete list. If you meet the criteria, you may file,
whether you officially served in one of these operations or not.
These are the four large 'umbrella' military operations in which
'Persian Gulf Veterans' have served.

Operation Desert
Shield

Operation Desert
Storm

Operation Iraqi
Freedom

Operation New Dawn

What
about Afghanistan?

Service in
Afghanistan after September 19, 2001, may grant you presumptive
service connection for a number of infectious
diseases, covered in Chapter V. These are 3.317(c) claims, but they are not medically
unexplained chronic multisymptom illnesses.
If you served in Afghanistan, but not in the Southwest Asia
Theater, you cannot make a 3.317(a) claim for a medically
unexplained chronic multisymptom illness.

If
you have a medically
unexplained chronic multisymptom illness or
a similar illness which you believe is service-connected, but you do
not meet the definition of a Persian Gulf Veteran as the VA defines
it, you may still file a claim. You may still receive benefits.
However, you will have a higher burden of proof, and the claim will
not fall under 3.317.

What
about the rest of the Global
War on Terror or even Cold
War claims of similar nature?

If you served
abroad, you exhibited symptoms of any infectious disease endemic to
that region where you served, and those symptoms emerged within one
year of your discharge, you have a sound basis to make a claim for
compensation related to that disease to the extent it is disabling.
You may have a higher burden of proof – the 'presumptive'
service connection covered in chapters II-V, at its essence, just
allows for a lower burden of proof.

Likewise, if you
have a disease which may have been caused by chemical or other
exposures in your military service, foreign or domestic, you may
file a claim for compensation. Your burden of proof is higher, and
it will not be a 3.317(a) claim.

You can win these
claims if you take time to meet the burden of proof, and it will
change your life for the better when you do. Please carefully
research your claim before you file it and contact the NGWRC if we
may help.

Where
is the current regulation posted?

Go
to http://www.benefits.va.gov/warms/bookb.asp
and scroll down to 3.317 to download it. These regulations change
frequently. You should download it when you are working on your
claim. Make a second copy and give it to your Veterans Service
Organization Representative (VSO Rep) with your other documentation,
unless you have a VSO Rep who already specializes in Persian Gulf
Claims.

Starting
your claim

GWI/CMI claims are difficult to prove. They involve a combination
of undiagnosed symptoms and illnesses which, by definition, are
medically unexplained. Because of this, Congress lowered the burned
of proof. If you have the symptoms or the medically unexplained
illnesses, and you served in the Southwest Asia Theater (SWAT) of
Operations after 1990, the VA will presume that your illness is
service connected.

You must document your symptoms and their severity, sort out which
have become parts of a diagnosis and which remain undiagnosed, and
prove your SWAT service in order to establish your claim.

CRITICALLY
IMPORTANT CLAIM PROTOCOL

Sometimes, Iraq
and Persian Gulf veterans have both diagnosed conditions and
undiagnosed symptoms which can be claimed under §3.317(a).
Once a symptom is 'claimed by' a diagnosis, it may no longer be
claimed as part of 'undiagnosed illness'.

Sorting out your
symptoms and your diagnoses is important to building a strong claim
for compensation under §3.317(a).
If you have a medically unexplained CMI diagnosis, you need to file
for that under §3.317(a)(2)(i)(B).
You need to remove all symptoms related to your diagnosed CMI's
from any claim you might make for undiagnosed illness under
§3.317(a)(2)(i)(A).

Here is the
complete list of signs and symptoms of qualifying Chronic
Multisymptom Illnesses, quoted directly from §3.317(b):

Fatigue.

Signs
or symptoms involving skin.

Headache.

Muscle
pain.

Joint
pain.

Neurological
signs or symptoms.

Neuropsychological
signs or symptoms.

Signs
or symptoms involving the respiratory system (upper or lower).

Sleep
disturbances.

Gastrointestinal
signs or symptoms.

Cardiovascular
signs or symptoms.

Abnormal
weight loss.

Menstrual
disorders.

You may be
wondering how to be a little more specific, and how it helps
your claim when you are. Your claim is strongest if you can match
up your symptoms to show that they cover at least two of the six
categories in the Institute of Medicine (IOM) definition of CMI.
Here is an outline of each of the six IOM categories, and some of
the symptoms which the match up with them:

In
addition, skin disorders, chest pain, heart palpitations, abnormal
weight loss, menstrual disorders, and any other symptoms that fall
under the thirteen signs and symptoms should be explained and
defined to the best of your ability before you begin this type of
claim.

Please
remember that each symptom must be a 'medically unexplained
symptom' in order to qualify you for compensation under
38CFR§3.317(a). Other medical diagnostic terms with
similar meaning to 'medically unexplained' are 'functional',
'somatoform', and 'idiopathic'. If your doctor uses
any of those words to define the cause of your symptoms, or to
diagnose them, they are usually 'medically unexplained'.

As you prepare
your claim, remember to list all your symptoms which fall under
these categories, and each diagnosis. Match up the symptoms to the
diagnoses you have, so that you don't include a 'diagnosed symptom'
in a claim for undiagnosed illness. If you also have a Traumatic
Brain Injury (TBI) or a Post-Traumatic Stress Disorder (PTSD)
diagnosis, consult with your doctor and your VSO Rep about where to
assign overlapping symptoms which may result from more than one of
those causes. You may be able to list symptoms under more than one
diagnosis, but you may never list those same symptoms as
'undiagnosed'.

Here is an
example for a veteran who does not have TBI or PTSD:

diagnoses
the veteran has

Chronic Fatigue
Syndrome-CFS

Irritable Bowel
Syndrome-IBS

undiagnosed
symptoms - not part of any diagnosis

neuropathies

paralysis of
left arm

symptoms
the veteran has - these are part of a diagnosis

unrefreshing
sleepCFS

multi-joint
pain without swelling or rednessCFS

muscle
painCFS

a sore
throat that is frequent or recurringCFS

significant
impairment of short-term memory/concentrationCFS

diarrhea
some daysIBS

constipation
other daysIBS

bloatingIBS

mucus in
stoolIBS

symptoms that are not part of IBS or CFS - these are the "undiagnosed illness"

multiple
medically unexplained debilitating neuropathies

medically
unexplained paralysis of left arm

In the above
case, the veteran has been diagnosed with CFS and IBS [CFR
38, §3.317(a)(2)(i)(B)].
He or she will file claims for both of those. He will not file a
claim for the nine symptoms related to either CFS or IBS. This
veteran also has multiple
medically unexplained debilitating neuropathies and medically
unexplained paralysis of left arm. Because those last two symptoms
have not been tied to a diagnosis,
they may still be claimed as undiagnosed illness [CFR
38, §3.317(a)(2)(i)(A)].
The veteran will make a total of four §3.317(a)
claims: CFS, IBS, neuropathies, paralysis.

If you have been
diagnosed with at least one CMI – CFS, FM, IBS, some other
functional gastrointestinal disorder, or any diagnosed condition
which falls under the CMI rule – make sure you file for each
one as a separate, unique
presumptive service connected disability due to your Persian Gulf
service, per section 3.317 of title 38 of the CFR.

It is important
that this wording is together with these illnesses on your claim
forms.

Remember: most
adjudicators are not doctors, and these are unusual claims. This
wording tells them where to look up the law which should guide their
determination. If you don't help them find the information they
need to resolve your claim fairly, there is a good chance they
won't.

On many
occasions, VSO Reps have left this wording out, and valid claims
were denied.

After you have
listed each diagnosis, continue with individual symptoms which are
undiagnosed. Each of the undiagnosed symptoms is filed in a similar
fashion. “I am filing a claim for headaches as a presumptive
service connected disability due to my service in the Gulf War per
section 3.317 of title 38 of the CFR.”

The form 21-526
(claim for disability compensation) will let you list each symptom
due to the gulf war, but you should also fill out a 21-4138
(statement in support of claim) and list out each of your symptoms
in a statement. Fill out a separate 21-4138 for each symptom. This
will keep it clean.

Lay
evidence - Build a record of your symptoms to prove your case

Any
statement provided by someone other than a health care professional
is lay evidence when presented as part of a claim for disability
compensation to the VA.

Lay
evidence is an important part of a claim for any medically
unexplained CMI, diagnosed or not. The first and most important
source of lay evidence for your claim is you. Once you have your
symptoms all written out, and a log of when they occur, how often
they occur, and how severe they are, you may take that to your
doctor as the starting point to build up medical evidence.

First,
keep a log of your own that details your symptoms. Use as much
detail and description as you can. Here are a couple example
symptoms and how you should explain them in your own log:

If
you have headaches, do not just say “I have a headache
and it lasts all day”, describe every detail of the headache.
Answer all of the following questions. What is the onset like?
Does it feel like it starts in a specific spot? Where is that?
Does it move from one place in your head to another? Does it feel
like it grows to affect a larger area over time? Where does it
expand to? How long does it take? Does the pain increase in each
place affected, or only cover more territory? Are you still able to
work with the headache? Does it affect your temper? Does it make
it hard to write, type, or do calculations? Does it make it hard to
walk, use your hands in manual labor, or play an instrument? Are
you incapacitated, forced to sit in a chair or lie in bed, doing
nothing else, until the headache subsides or goes away? What were
you doing when the headache started? Does the headache start during
the day, night or both? How long does it last and do you have more
than one type of headache? Does it ever go away completely?

If
you have diarrhea, do not just say “I have diarrhea all
the time.” You need to state exactly how many times a day you
go to the bathroom. Example: “When the diarrhea comes I have
use to the stool about [seven] times, once every [30 minutes] over a
period of [three to four hours]. At least once during that time, I
cannot leave the bathroom at all for [about an hour]. This happens
[once or twice a day], about [10 times every week].” Re-write
that in a way that accurately describes your experience, and you
have something that will help your claim. You will have to state
how it comes on; how long it lasts, any pain or discomfort, and
whether or not you have constipation afterward. State if you take
any medication for the diarrhea, whether it's over-the-counter or
prescribed, and whether it is working or not.

For
each of the symptoms, you should be going to your doctor at the VA,
or at least calling the VA and asking what to do. This is not only
to get treatment for your symptoms, but to build a paper trail to
support your case. These calls to the VA usually go into your file.
Your medical file establishes a record of the number and severity
of your symptoms which helps you establish your claim.

Look
carefully over all the chronic multi-symptom type illnesses in
Chapter IV and the diagnostic criteria that the VA has for some of
these illnesses. If you believe you may have an illness such as
chronic fatigue syndrome (CFS), talk to your Doctor about it. If
you are likely to be diagnosed with CFS or fibromyalgia, make sure
to account for that in developing your claim before you continue to
the undiagnosed illness part of the claim. If you have enough
information to rule those out, proceed with your undiagnosed illness
claim in chapter III.

Statements
in Support of Claim

You
should write a statement in support of claim [VA form 21-4138] for
each diagnosed CMI you are claiming, and for each symptom of
undiagnosed illness. You may also have family members, co-workers,
friends, and people you served with fill out this form. The form
can be downloaded as a fillable PDF form at
http://www.va.gov/vaforms/form_detail.asp?FormNo=21-4138.

Work
with a Veteran Service Organization Representative (VSO Rep) to
complete & file a claim

Find
a VSO Rep, often called a Veterans Service Officer outside
the VA, with knowledge and experience specific to Gulf War claims,
and have him or her help you file your claim. It is important that
you specifically mention that you are claiming a presumptive
service connection due to your service in the Southwest Asia Theater
(Persian Gulf) per section 3.317 of title 38 of the CFR. As you
get into specific forms, the 21-526 will let you list each symptom
due to the gulf war. However, you should also fill out a 21-4138
and list out your symptoms in a statement. Fill out one 4138 per
symptom.

If
you are filing for CFS, fibromyalgia (FM), IBS, or any other
diagnosed CMI which is medically unexplained, please refer to
Chapter IV of this guide. Each will be filed in a similar fashion,
and each must mention that you are filing it as a presumptive
service connection due to your service in the Southwest Asia Theater
(Persian Gulf) per section 3.317 of title 38 of the CFR.

Chapter III: Gulf War Illness/CMI Claim –
Undiagnosed Illness

[CFR
38, §3.317(a)...(A)]

Introduction

This is a guide to filing a claim
for disability compensation for Undiagnosed Illness in Persian Gulf
Veterans. What we in common language call Gulf
War Illness (GWI) be
either
an undiagnosed
illnessor amedically
unexplained chronic multisymptom illnesses,
such as, but not limited to, chronic
fatigue syndrome (CFS), fibromyalgia, functional gastrointestinal
disorders.

If you have been diagnosed with amedically
unexplained chronic multisymptom illness such as CFS, fibromyalgia, or a functional
gastrointestinal disorder, please go to Chapter IV for those
specific diagnoses. You may get a faster response on your claim by
filing under the diagnosis. Filing for undiagnosed illness at the
same time may delay your claim.

This chapter only addresses the part of your claim related to
undiagnosed symptoms.

Undiagnosed Illness in Persian Gulf Veterans – Who may file
a claim?

If
you have undiagnosed symptoms of Gulf War Illness/Chronic
Multisymptom Illness, and you served in Iraq or the Persian Gulf
while in the US Military after 1990, you may file a claim as long as
the symptoms manifest before the end of 2016. Please
refer to page 17 in Chapter II for detailed definitions of Persian
Gulf War Service (which includes most OIF and other Iraq veterans)
and the Southwest Asia Theater (SWAT) of Operations.

If
you have a medically
unexplained chronic multisymptom illness or
similar illness which you believe is service-connected, but you do
not meet the definition of a Persian Gulf Veteran (nearly all Iraq
veterans count as 'Persian Gulf' veterans) as the VA defines it, you
may still file a claim. You may still receive benefits; however,
you will have a higher burden of proof, and the claim will not fall
under 3.317(a). Please contact the NGWRC if we may help you file a
claim related to undiagnosed or unexplained illness which may be
related to chemical or other exposures outside SWAT.

Preparing a claim for undiagnosed illness

A
claim under section 3.317(a) for undiagnosed illness can be one of
the hardest ones to work. Many veteran service organization
representatives (VSO Reps) have a hard time preparing these claims
or appealing a denial. DO NOT file for one of the
38CFR§3.317(a)(2)(i)(B)
presumptive illnesses listed on page 16 unless you have a diagnosis
of that illness. If you have a 38CFR§3.317(a)(2)(i)(B)
illness, refer to Chapter IV. Use the information in this chapter
to help prepare a claim for undiagnosed illness, or for specific
symptoms which have not been associated with any diagnosis.

If
you have a diagnosed illness with the same symptoms, but it is not
listed on page 16 and is not a medically unexplained chronic
multisymptom illness as outlined in the regulation, then you should
file under a different section of VA regulations. You do not have a
3.317(a) claim for presumptive service connection.

List
your signs and symptoms, and separate out those which are
undiagnosed

List
out each and every one of the symptoms that you have. As you list
each symptom, include the date it first appeared – you may
refer to page 19 in Chapter II for the list of signs and symptoms.
Once you have all your symptoms listed, sort out those which are
undiagnosed, covered here, and those which are part of a diagnosis,
covered in Chapter IV. An example of how to do that is listed on
page 20 in chapter II.

If
you have a diagnosis, such as Chronic Fatigue Syndrome (CFS),
remember to list only those symptoms which are not CFS (or any other diagnosis) in your claim for undiagnosed illness.
You may claim both the CFS and the completely undiagnosed symptoms,
but they are separate issues in the VA's eyes. If you confuse the
issues in your claim, that may delay your claim. It may even
increase your claim's chance of being denied by confusing the
adjudicator.

For
CFS, FM, IBS, or any other 'medically unexplained',
'functional' or 'somatoform' diagnosis, refer to Chapter IV for that part of your claim.

There is a
presumptive end-date, December 31, 2016, for the symptoms to
manifest, but you may file your claim after that date as long as you
have a record of symptoms going back to 2016 or earlier.

Refer to
Chapter II for details related to filing your claim.

Key
elements that must be established in your claim

To
receive a rating for undiagnosed illness in Persian Gulf veterans,
you need to prove the following to the VA:

US Military Service in the
Southwest Asia Theater between 1990 and the current date*.

You have some of the thirteen
'signs and symptoms' but no diagnosis to explain them.

The symptoms began before the end of 2016. Go back as far as you
can.

*The
VA is considering an 'end date' to 'Persian Gulf War Service' of
December 18, 2011, the last day of Operation New Dawn. If this 'end
date' is eventually approved, you will need to show evidence of SWAT
service between August 2, 1990 and December 18, 2011 to gain
presumptive service-connection.

This
is a guide to filing a claim for disability compensation if
you have been diagnosed with amedically
unexplained chronic multisymptom illness (CMI)
such as, but not limited to, chronic fatigue syndrome (CFS),
fibromyalgia (FM), or a functional gastrointestinal disorder like
irritable bowel syndrome (IBS).

What
we in common language call Gulf
War Illness (GWI) is
always a CMI. It can be either an undiagnosed
CMIor amedically
unexplained CMI diagnosis.

This
chapter covers only diagnosed CMIs covered by [CFR 38,
§3.317(a)(2)(i)(B)]. To
make a claim for Undiagnosed Illness in Persian Gulf Veterans,
please go to Chapter III.

If
you have both diagnosed CMIs and undiagnosed symptoms, make sure to
file a claim for each diagnosis first. Never include symptoms of
your diagnosed CMI's (such as CFS, FM, or IBS) in your claim for
undiagnosed illness.

If
you confuse the issues in your claim, that may delay your claim. It
may even increase your chance of denial by confusing the
adjudicator. Some veterans have success by filing only for their
diagnosed CMI's first. Then, after those claims are granted, they
go back and file for any remaining undiagnosed symptoms.

What
counts as a medically unexplained chronic multisymptom
illness?

CFR
38, §3.317(a)(2)(i)
reads as follows:

For
purposes of this section, a qualifying
chronic disability means a chronic disability resulting from any of the following (or
any combination of the following):

(A)
An undiagnosed illness;

(B)
A medically unexplained chronic multisymptom illness that is defined
by a cluster of signs or symptoms, such as:

Your
claim is not limited to CFS,
FM, or functional gastrointestinal disorders. Any diagnosis you
have which meets the 'signs
and symptoms'
criteria, and which is also chronic,
multisymptom,
and medically
unexplained,
can be used to file a claim under CFR
38, §3.317(a)(2)(i)(B)

Medically
unexplained has a very similar meaning to 'functional',
'somatoform',
and 'idiopathic' in medical terminology when diagnosing a condition. If your doctor
diagnoses you with something, and you think it may be related to
your service in Iraq or the Persian Gulf, it is appropriate to ask
more questions about the diagnosis, to find out if it is 'medically
unexplained', 'functional',
or 'somatoform'.
If the illness is also chronic (you have it for longer than six months), and multisymptom,
either by itself or together with other medically unexplained
conditions, then it may be part of your claim for VA compensation
under CFR 38, §3.317(a)(2)(i)(B).

Please
refer to page 19 in Chapter II for a complete list of 'signs and
symptoms' associated with CMI related to Persian Gulf or Iraq
service.

Are
they all Gulf War Illness?

All illnesses named
in CFR
38, §3.317(a)(2)(i)(B),
or which meet the same criteria, have been determined by law, after
scientific review of medical studies, as being 'at least as likely
as not' connected to service in the Southwest Asia Theater (SWAT) in
the year 1990 or later. So, in that sense, whether you have
'undiagnosed illness', CFS, FM, IBS, or a similar somatoform diagnosis not specifically named in the CFR, you have 'Gulf War
Illness'.

What
makes these CFR
38, §3.317(a)(2)(i)(B)
diagnoses different
from undiagnosed illness?

In truth, each of
the CMI's covered by CFR
38, §3.317(a)(2)(i)(B)
contains a subset of symptoms which closely overlaps at least one of
the symptoms associated with Gulf War Illness. However, once you
have the diagnosis, you are required by law to file for compensation
benefits under that diagnosis, not claim it as 'undiagnosed
illness'. If you have additional symptoms which fall outside the
definition of your diagnosis, you may still claim those symptoms
separately as 'undiagnosed illness'.

Filing
your Claim

Why
are diagnosed CMI's done as a separate claim from undiagnosed
illness?

If
you file in a way that is essentially asking the VA to compensate
you twice for the same symptom (e.g. once as part of CFS and again
as part of undiagnosed illness), it is highly likely that your claim
will be delayed, denied, or both.

What
diseases are specifically mentioned in CFR
38, §3.317(a)(2)(i)(B)?

Remember,
you may claim any diagnosis which meets the criteria, whether it is
listed here or not.

What
diseases other than those named in CFR
38, §3.317(a)(2)(i)(B)
are allowed?

There
is no list for the 'other' diagnoses. Each regional office, and
frequently each individual claim adjudicator, is on their own when
trying to determine if a diagnosis meets the criteria of medically
unexplained CMI and the 13
signs and symptoms,
or not. While you must, by law, file any diagnosis under CFR 38, §3.317(a)(2)(i)(B)
whether that particular diagnosis is listed there or not, the burden
of proof is more like undiagnosed illness. The difference is: now
you need to prove that the diagnosis meets a subset of the criteria,
which are the same whether the condition is diagnosed or not.

First,
if the diagnosis is not one of those named in the CFR, make sure you
can establish in your claim that your diagnosis meets, i.e. strongly
overlaps, the criteria of explained in Chapter II starting on page
19. You should have a doctor sign an affidavit to that effect if
possible.

Most
adjudicators are not doctors; if it is not on their list, they may
simply deny it unless you go the extra mile to prove the case to
them.

If
you have been diagnosed with at least one CMI – CFS, FM, IBS,
some other functional gastrointestinal disorder, or any diagnosed
condition which falls under the CMI rule – make sure you file
for each one as a separate, uniquepresumptive
service connected disability due to your service in the Gulf War,
per section 3.317 of title 38 of the CFR.

How
are Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM) alike?

Fibromyalgia
and chronic fatigue syndrome are very similar illnesses. In fact, up
to 70% of their symptoms overlap. Overlapping symptoms include:

They can be Concurrent Disorders. It is
possible to suffer from both fibromyalgia and CFS at the same time.
In fact, between 20% and 30% of fibromyalgia sufferers have CFS. 35%
of chronic fatigue patients also have fibromyalgia. It has been
theorized that CFS is actually a sub-disorder of the fibromyalgia
syndrome.

Why
is it so important to get tested for CFS (if you already have FM)?

You
may be asking yourself: What difference does it make if
you have CFS or FM?

The
VA may grant you a 100% service-connected disability rating on CFS
by itself, $2,816.00 per month, if the symptoms are severe enough.
The highest rating allowed for FM is 40%, $569.00 per month. That
is a difference of up to $2,247.00 in untaxed compensation every
month, for two different veterans with no dependents –
identical symptoms but different diagnoses (the FM diagnosis being
incomplete or incorrect). If you have a family, the amount –
and the loss of income – is greater; all because you got the
wrong diagnosis, FM alone, when you really have CFS (either instead
of, or in addition to, FM).

Many
veterans who meet the criteria for CFS never get properly tested for
CFS. Instead they are diagnosed with FM only, denied the
compensation they deserve because of that.

There
is a specific test for CFS. Make sure you get that test done, and
you know the results, before you file a claim for any CMI. If you
have CFS, and your symptoms are severe, it may bring you more
benefits than any other one condition.

Chronic Fatigue
Syndrome (CFS)

Chronic
fatigue syndrome (CFS) is a condition that makes you feel so tired
that you can't do all of your normal, daily activities. There are
other symptoms too, but being very tired for at least 6 months is
the main one. Myalgic encephalomyelitis (ME) is
another name for CFS. Sometimes you will see the acronym ME/CFS
used to refer to CFS.

The
illness is characterized by prolonged, debilitating fatigue and a
characteristic group of accompanying symptoms, particularly problems
with memory and concentration, unrefreshing sleep, muscle and joint
pain, headache, and recurrent sore throat. It is marked by a
dramatic difference in pre- and post-illness activity level and
stamina.

The
disease is not well understood. Most experts now believe that it is
a separate illness with its own set of symptoms, but some doctors do
not believe this.

There
is no simple test for CFS, making it difficult to recognize. The
process of 'testing for CFS' is really a battery of tests to rule
everything else out. Because it is hard to diagnose, many people
have trouble accepting their disease or getting their friends and
family to do so. Having people who believe your diagnosis and
support you is very important. Having a doctor you can trust is
critical.

Your
tiredness is real. It’s not “in your head.” It is
your body's reaction to a combination of emotional and physical
factors. In the case of most SWAT veterans with CFS, it is the
body's reaction to a complex combination of unhealthy exposures and
conditions acting together to create the illness.

Diagnostic
Resources

The
Centers for Disease Control created resources to assist health care
professionals in diagnosing and managing CFS. It may work best if
you can get your doctor to spend time browsing the resources, but
you may also print out resources for your care giver, your VSO Rep,
and perhaps even to go with your claim. They may be accessed here: CFS
Toolkit and additional information for health care professionals

What causes CFS?

Of
all chronic illnesses, CFS is one of the most mysterious. Several
possible causes have been proposed, including:

Depression

Iron
deficiency anemia

Low
blood sugar (hypoglycemia)

History
of allergies

Virus
infection, such as Epstein-Barr virus or human herpes virus 6

Dysfunction
in the immune system

Changes
in the levels of hormones produced in the hypothalamus, pituitary
glands or adrenal glands

A
good link for up to date information is this one at the Mayo
Clinic.

Symptoms
similar to those of CFS sometimes have straightforward, correctable
causes, such as:

An
active, identifiable medical condition that often results in
fatigue

Medication
side-effects

What
are the symptoms?

A
CFS diagnosis should be considered in patients who present with six
months or more of unexplained fatigue accompanied by other
characteristic symptoms. These symptoms include:

cognitive
dysfunction, including impaired memory or concentration

postexertional
malaise lasting more than 24 hours (exhaustion and increased
symptoms) following physical or mental exercise

unrefreshing
sleep

joint
pain (without redness or swelling)

persistent
muscle pain

headaches
of a new type or severity

tender
cervical or axillary lymph nodes

sore
throat

Other
Common Symptoms

In
addition to the eight primary defining symptoms of CFS, a number of
other symptoms have been reported by some CFS patients. The
frequency of occurrence of these symptoms varies among patients.
These symptoms include:

Clinicians
will need to consider whether such symptoms relate to a comorbid or
an exclusionary condition; they should not be considered as part of
CFS other than how they can contribute to impair functioning.

Finding
the right doctor

The
more you know about CFS the better prepared you'll be when trying to
find a doctor. It's a difficult process, and you may need to educate
a few health-care professionals along the way. Be sure you know the list of symptoms and become familiar
with the various ways CFS is treated.

The
crux of the problem is that no medical specialty has "claimed"
CFS, so finding a knowledgeable doctor isn't as easy as with most
illnesses. Even fibromyalgia,
which is considered closely
related to CFS,
falls under the auspices of rheumatology. CFS is not well
understood, and many health-care providers have a hard time
recognizing it. Some don't even believe it is an actual condition.

This
means that the burden of finding someone qualified to treat you
falls squarely on your shoulders. However, you have a number of
resources to use in your search.

Your
primary care provider
If your regular doctor isn't well
educated about CFS, see if he or she is willing to learn or knows
of someone who is more knowledgeable.

Other
care providers
If you see a physical therapist, massage
therapist or chiropractor, ask whom he or she would recommend.

Local
support groups
People involved in local support groups
likely will be able to recommend qualified doctors. To find a
support group in your area, you can check with your doctor, local
clinics and hospitals.

Advocacy
groups
CFS
advocacy group websites may be able to help. Check out this
patient-recommended "good
doctor"
list from Co-Cure.

Friends,
family and associates
Talk to everyone you know to see if
they can recommend a doctor, or whether they know someone with CFS
who may be able to recommend one. While most people aren't
qualified to say whether a doctor is competent, they can tell you
whether he or she is compassionate, patient and willing to go an
extra mile for you.

Referral
services Check with local clinics and hospitals to see if they
have referral services. Also, call your insurance company to see if
they have any doctors listed as specializing in CFS.

How is CFS
diagnosed?

A
CFS diagnosis is not based on one single test, but a battery of
tests, measurements of symptoms, and questionnaires, done to rule
out other possibilities and ultimately give the diagnosis of CFS.
You may learn more about the protocol from the Centers for Disease
Control by following this link: http://www.cdc.gov/cfs/diagnosis/ .

You
cannot self-diagnose CFS. Many other health problems can cause
fatigue, and most people with fatigue have something other than
chronic fatigue syndrome.

How is CFS
treated?

There
is no treatment for CFS itself, but many of its symptoms can be
treated. A good relationship with your doctor is important, because
the two of you will need to work together to find a combination of
medicines and behavior changes that will help you get better. Some
trial and error may be necessary, because no single combination of
treatments works for everyone.

Home
treatment is very important. You may need to change your daily
schedule, learn better sleep habits, and start getting regular
gentle exercise.

Counseling
and a gradual increase in exercise help people with CFS get better.

Even
though it may not be easy, keeping a good attitude really helps. Try
not to get caught in a cycle of frustration, anger, and depression.
Learning to cope with your symptoms and talking to others who have
the same illness can help you keep a good attitude.

Fibromyalgia
(FM)

Fibromyalgia
(FM) is a syndrome predominately characterized by widespread
muscular pains and fatigue. The causes of FM are unknown. There are
difficulties in diagnosing FM. Its clinical picture can overlap
other illnesses, and there are no definitive diagnostic tests.
Patient education, pharmacologic agents, and other nonpharmacologic
therapies are used to treat FM. Exercise has been found to improve
outcomes for people with FM. The medical community's understanding
of this disease is evolving. For more in-depth and up-to-date
information, visit the websites of the Mayo
Clinic or the Centers
for Disease Control.

Symptoms

Signs
and symptoms of FM can vary, depending on the weather, stress,
physical activity or even the time of day.

Widespread
pain and tender points

The pain associated
with FM is described as a constant dull ache, typically arising from
muscles. To be considered widespread, the pain must occur on both
sides of your body and above and below your waist.

Fibromyalgia
is characterized by additional pain when firm pressure is applied to
specific areas of your body, called tender points. Tender point
locations include:

Back
of the head

Between
shoulder blades

Top
of shoulders

Front
sides of neck

Upper
chest

Outer
elbows

Upper
hips

Sides
of hips

Inner
knees

Fatigue
and sleep disturbances

People
with FM often awaken tired, even though they seem to get plenty of
sleep. Experts believe that these people rarely reach the deep
restorative stage of sleep. Sleep disorders that have been linked
to FM include restless legs syndrome and sleep apnea.

Co-existing
conditions

Many
people who have fibromyalgia also may have:

Chronic
fatigue syndrome

Depression

Endometriosis

Headaches

Irritable
bowel syndrome (IBS)

Lupus

Osteoarthritis

Post-traumatic
stress disorder

Restless
legs syndrome

Rheumatoid
arthritis

Test
for FM

The
American College of Rheumatology has established two criteria for
the diagnosis of FM:

Widespread
pain lasting at least three months

At
least 11 positive tender points — out of a total possible of
18

Tender
points

During
your physical exam, your doctor may check specific places on your
body for tenderness. The amount of pressure used during this exam
is usually just enough to whiten the doctor's fingernail bed. These
18 tender points are a hallmark of FM.

Blood
tests

While
there is no lab test to confirm a diagnosis of FM, your doctor may
want to rule out other conditions that may have similar symptoms.
Blood tests may include:

Complete
blood count

Erythrocyte
sedimentation rate

Thyroid
function tests

Because
many of the signs and symptoms of FM are similar to various other
disorders, you may see several doctors before receiving a diagnosis.
Your family physician may refer you to a rheumatologist, a doctor
who specializes in the treatment of arthritis and other inflammatory
conditions.

What
you can do

You
may want to write a list that includes:

Detailed
descriptions of your symptoms

Information
about medical problems you've had in the past

Information
about the medical problems of your parents or siblings

All
the medications and dietary supplements you take

Questions
you want to ask the doctor

What
to expect from your doctorIn addition to a physical
exam, your doctor may check your neurological health by testing
your:

Reflexes

Muscle
strength

Muscle
tone

Senses
of touch and sight

Coordination

Balance

Associated
Conditions of Fibromyalgia

Fibromyalgia has often been called the "great imitator" because so
many of its symptoms mimic those of other disorders. As a result,
it can often be difficult to receive a proper diagnosis of FM.
However, there are subtle differences between many of the illnesses
and FM. Learning more about each of these disorders can help you
figure out just how FM is distinct from them.

A
rheumatologist can run the tests which you need to rule out the
above nine conditions. Only after you test negative for each of
these, can you be diagnosed with FM. It is possible to have
hypothyroidism and FM at the same time – but in that
situation, you cannot win a claim for FM until the other condition
has been treated and stabilized for six months, and the FM symptoms
persist.

People with FM are
also at greater risk of developing a number of other disorders,
many of which can exacerbate FM symptoms, or are linked to certain
conditions which may lead to fertility
problems.
Illnesses, diseases and conditions that fall into this category
include:

FM
can also impact your libido, which in turn affects sexual intimacy.
Find out why FM affects your sexual desire and learn about tips to
improve sexual intimacy in your relationship in the following via
the following link: Sexuality.

Functional
Gastrointestinal Disorders

Functional
Gastrointestinal Disorders are a group of digestive system disorders
which are medically unexplained because they have no structural
cause. CFR 38, §3.317(a)(2)(i)(B)(3) states that these
include, but are not
limited to:

Irritable
bowel syndrome (IBS)

Functional
dyspepsia

Functional
vomiting

Functional
constipation

Functional
bloating

Functional
abdominal pain syndrome

Functional
dysphagia.

All of the above
diagnoses count. If you have more than one, you may file a separate
claim for each diagnosis. By far the most common diagnosis among
Persian Gulf and Iraq veterans is IBS. Most of this section deals
with that diagnosis.

Functional vs
structural disorders

If there is a structural cause in your digestive tract, any symptom
connected to it is not a functional disorder. Structural causes include, but are not limited to, any tear, ulcer, polyp,
cancer, or improperly working valve in your digestive tract. You
may be able to claim a structural disorder, but it will not fall under §3.317(a).
You should seek other guidance before you submit a claim to the VA
for compensation related to any structural gastrointestinal disorder.

Irritable Bowel
Syndrome (IBS)

What is
irritable bowel syndrome (IBS)?

Irritable
bowel syndrome (IBS) is a disorder characterized most commonly by
cramping, abdominal pain, bloating, constipation, and diarrhea. IBS
causes a great deal of discomfort and distress, but it does not
permanently harm the intestines and does not lead to a serious
disease, such as cancer. Most people can control their symptoms with
diet, stress management, and prescribed medications. For some
people, however, IBS can be disabling. They may be unable to work,
attend social events, or even travel short distances.

As
many as 20 percent of the adult population, or one in five
Americans, have symptoms of IBS, making it one of the most common
disorders diagnosed by doctors. It occurs more often in women than
in men, and it begins before the age of 35 in about 50 percent of
people affected.

What are the
symptoms of IBS?

Abdominal
pain, bloating, and discomfort are the main symptoms of IBS.
However, symptoms can vary from person to person. Some people have
constipation, which means hard, difficult-to-pass, or infrequent
bowel movements. Often these people report straining and cramping
when trying to have a bowel movement but cannot eliminate any stool,
or they are able to eliminate only a small amount. If they are able
to have a bowel movement, there may be mucus in it, which is a fluid
that moistens and protect passages in the digestive system.

Some
people with IBS experience diarrhea, which is frequent, loose,
watery, stools. People with diarrhea frequently feel an urgent and
uncontrollable need to have a bowel movement. Other people with IBS
alternate between constipation and diarrhea. Sometimes people find
that their symptoms subside for a few months and then return, while
others report a constant worsening of symptoms over time.

Symptoms
include

Abdominal
pain or discomfort for at least 12 weeks out of the previous 12
months. These 12 weeks do not have to be consecutive.

The
abdominal pain or discomfort has two of the following three
features:

It
is relieved by having a bowel movement.

When
it starts, there is a change in how often you have a bowel
movement.

When
it starts, there is a change in the form of the stool or the way it
looks.

Certain
symptoms must also be present, such as

a
change in frequency of bowel movements

a
change in appearance of bowel movements

feelings
of uncontrollable urgency to have a bowel movement

difficulty
or inability to pass stool

mucus
in the stool

bloating

Bleeding,
fever, weight loss, and persistent severe pain are not symptoms of
IBS and may indicate other problems such as inflammation, or
rarely, cancer.

The
following have been associated with a worsening of IBS symptoms

large
meals

bloating
from gas in the colon

medicines

wheat,
rye, barley, chocolate, milk products, or alcohol

drinks
with caffeine, such as coffee, tea, or colas

stress,
conflict, or emotional upsets

Researchers
have found that women with IBS may have more symptoms during their
menstrual periods, suggesting that reproductive hormones can worsen
IBS problems.

In addition,
people with IBS frequently suffer from depression and anxiety,
which can worsen symptoms. Similarly, the symptoms associated with
IBS can cause a person to feel depressed and anxious.

How is IBS
diagnosed?

If you think you
have IBS, seeing your doctor is the first step. IBS is generally
diagnosed on the basis of a complete medical history that includes
a careful description of symptoms and a physical examination.

There is no
specific test for IBS, although diagnostic tests may be performed
to rule out other problems. These tests may include stool sample
testing, blood tests, and x-rays. Typically, a doctor will perform
a sigmoidoscopy, or colonoscopy, which allows the doctor to look
inside the colon. This is done by inserting a small, flexible tube
with a camera on the end of it through the anus. The camera then
transfers the images of your colon onto a large screen for the
doctor to see it.

If your test
results are negative, the doctor may diagnose IBS based on your
symptoms, including how often you have had abdominal pain or
discomfort during the past year, when the pain starts and stops in
relation to bowel function, and how your bowel frequency and stool
consistency have changed. Many doctors refer to a list of specific
symptoms that must be present to make a diagnosis of IBS.

How does stress
affect IBS?

Stress—feeling
mentally or emotionally tense, troubled, angry, or overwhelmed—can
stimulate colon spasms in people with IBS. The colon has many
nerves that connect it to the brain. Like the heart and the lungs,
the colon is partly controlled by the autonomic nervous system,
which responds to stress. These nerves control the normal
contractions of the colon and cause abdominal discomfort at
stressful times. People often experience cramps or “butterflies”
when they are nervous or upset. In people with IBS, the colon can
be overly responsive to even slight conflict or stress. Stress
makes the mind more aware of the sensations that arise in the
colon, making the person perceive these sensations as unpleasant.

Some evidence
suggests that IBS is affected by the immune system, which fights
infection in the body. The immune system is affected by stress.
For all these reasons, stress management is an important part of
treatment for IBS. Stress management options include:

stress
reduction (relaxation) training and relaxation therapies such as
meditation

counseling
and support

regular
exercise such as walking or yoga

changes
to the stressful situations in your life

adequate
sleep

CHAPTER V – Other
Iraq/Gulf/Afghanistan Claims: Infectious Diseases

[CFR
38, §3.317(c-d)]

Introduction

Paragraph
(c) of§3.317
grants presumptive service connection for nineinfectious diseases
which are endemic to many parts of the world, including Iraq,
Afghanistan,
and the Persian
Gulf.
Please read this chapter carefully if it may apply to you; the
requirements for presumptive service connection are not the same
for each disease.

The
nine diseases are (i)
Brucellosis, (ii)
Campylobacter jejuni, (iii) Coxiella burnetii (Q fever), (iv)
Malaria, (v) Mycobacterium tuberculosis, (vi) Nontyphoid
Salmonella, (vii) Shigella, (viii) Visceral leishmaniasis, and(ix)
West Nile virus.
The manifestation time limits – based on how long each
disease may take to incubate – are different, so they are
divided up accordingly below.

Many of these
diseases can lead to other health issues down the road. Getting
the initial disease on the record and connected to your service
ASAP protects your rights and your ability to take care of yourself
later on.

Who
is covered by this section?

CFR
38, §3.317(c)
applies to all veterans who served in Iraq
and the Persian
Gulf
after Aug 2, 1990, and all veterans who served in Afghanistan
after September 19, 2001.

If you served in some other overseas location and have
one of the nine diseases, you may still file a claim under the
normal standards – you simply have a higher burden of proof.

Is there a time limit for the symptoms to manifest?

Yes, in most cases there is a time limit for automatic
presumption of service-connection. However, if there is medical
evidence or a doctor's opinion to validate your claim of
service-connection, you should file even if you do not meet the
presumptive deadline. The VA has a legal obligation to consider a
valid claim on its merits, but it will hold you to a higher
standard of evidence if you miss the presumptive window.

What are the six diseases with a one year
manifestation requirement for presumption?

Most veterans have one year from their final date of
separation to manifest symptoms of the following diseases to meet
3.317(c) guidelines for presumptive service-connection of:

Brucellosis.

Campylobacter
jejuni.

Coxiella
burnetii (Q fever).

Nontyphoid
Salmonella.

Shigella.

West Nile
virus.

The
disease must be considered to 'have become manifest to a degree of
10 percent or more within one year from the date of separation' to
qualify. It is important to get it service-connected as soon as you
can, even if it doesn't bother you much today. You don't know when
secondary health issues will follow or how bad they will get.

Is
Malaria limited to one year, or not?

Malariais
also limited to one year after your discharge for the time being, and it must manifest to a
degree of 10 percent in that time. The VA reserves the right to
allow a longer presumptive period in the future, without a new law
from congress, if research supports that.

The
last two diseases have no
time limit to
manifest

There are two diseases which will be presumptively
service-connected unless proven otherwise, no matter how long they
take to manifest.

They are mycobacterium
tuberculosisandvisceral
leishmaniasis.

Secondary
Conditions and Filing a Claim on them

CFR
38, §3.317(d)
addresses the long term health consequences of the diseases named
in §3.317(c).
They are not presumptively service-connected at this time.
However, the VA recognizes a potential connection between the
infectious disease (listed in column A in the table below) and the
associated long-term health effects beside it (in column B).

Once you have your rating for one of the nine
infectious diseases, you should look at the long-term effects
associated with it. If any of those impact your own health, then
you should seek out medical opinions and pursue a claim.

Before
granting any of these secondary claims, the VA must receive a
medical opinion from a doctor that: 'it
is at least as likely as not that the condition was caused by the
veteran having had the associated disease' (in column A).

You may file the
claim and let the VA send you to their doctor for his opinion
(which they have the right to do regardless), or you may get a
doctor's statement on your own and submit it with your claim.
While the VA may still get a second opinion from its own doctor,
your claim will be stronger with a doctor supporting your 'at
least as likely as not' position. The VA's doctor is more
likely to agree with your claim if you already have a doctor
supporting you.

Table of Associated Long Term Health Effects

Here
is the full table from CFR
38, §3.317(d)
showing the associations which were found by the Institute of
Medicine at the National Academy of Sciences:

Long-term
adverse health outcomes due to irreversible tissue damage
from severe forms of pulmonary and extrapulmonary tuberculosis
and active tuberculosis.

Nontyphoid
Salmonella

Reactive Arthritis if
manifest within 3 months of the infection.

Shigella

Hemolytic-uremic
syndrome if
manifest within 1 month of the infection.

Reactive
Arthritis if
manifest within 3 months of the infection.

Visceral
leishmaniasis

Delayed presentation of the acute clinical syndrome.

Post-kala-azar
dermal leishmaniasis if
manifest within 2 years of the
infection.

Reactivation
of visceral leishmaniasis in the context of future immunosuppression.

West
Nile virus

Variable physical, functional, or cognitive disability.

CHAPTER VI – Traumatic
Brain Injury

What
is Traumatic Brain Injury?

Traumatic Brain Injury (TBI) is an injury to
the brain which can be directly identified and diagnosed with
medical scans and tests. It should be linked to one or more
specific events, such as a vehicle crash, IED explosion, fall, or
other impacts. Here is the VA's lay definition of
TBI:

A TBI happens when something
outside the body hits the head with significant force. This could
happen when a head hits a windshield during a car accident. It
could happen when a piece of shrapnel enters the brain. Or it could
happen during an explosion of an improvised explosive device (IED).

TBI is one of the things which should be
tested for before moving on to consider a possible diagnosis of
PTSD or a medically unexplained CMI. Once you are diagnosed with a
TBI, and you can trace it to an event during military service, the
process of obtaining service-connection for the injury is more
clear-cut than for some of the other disabilities discussed in this
guide.

If you have a TBI incurred during military
service, and you are not utilizing the robust array of VA medical
care options and services available, you may learn more here:
http://www.polytrauma.va.gov/.

What
are the symptoms?

The
VA divides the symptoms into categories as follows

Physical
effects

fractures

fever

difficulty
eating and speaking

degraded
vision

fatigue

loss
of hearing and sense of touch

Behavioral effects

anxiety

agitation

frustration

impulsiveness

repetitiveness

depression

regression (return to childlike behavior)

disinhibition (inability to control impulsive
behavior and emotions)

Cognitive effects

lack of attention and concentration

memory loss

lack of judgment

communication problems.

This
is not a complete list of all possible symptoms.

The Defense and Veterans Brain Injury Center
(DVBIC), part of the U.S. military health system, provides a
training video at
http://www.brainlinemilitary.org/conditions_course/introduction.php which is
designed for caregivers dealing with TBI. It recognizes these
categories of symptoms and secondary conditions: sleep,
mood, pain & headache, stress, attention & memory,
substance abuse.

What
secondary conditions are recognized by the VA?

The VA is still processing newly proposed
rules. They are not yet part of the Code of Federal Regulations;
however, research shows that these conditions may result from a
TBI:

Parkinsonism

Unprovoked
Seizures

Dementias
(presenile Alzheimer and post-traumatic)

Depression

Diseases
of hormone deficiency that result from hypothalamo-pituitary

These come from the Institute of Medicine's
(IOM) 2008 report, Gulf War and Health, Volume 7:
Long-term Consequences of Traumatic Brain Injury. The
IOM found each of these five conditions to be related to TBI with
the highest level of confidence they recognize.

At the time of this writing, none of these is
a presumptive condition. However, if you provide the supporting
information to your doctor, he or she is likely to give you an 'as
likely as not' letter to support your claim for these
conditions which frequently result from a TBI.

The
proposed change to 38 CFR §
3.310 will add a paragraph D to include the following:

(1) In a veteran
who has a service-connected traumatic brain injury, the following
shall be held to be the proximate result of the service-connected
traumatic brain injury (TBI), in the absence of clear evidence to
the contrary:

(i) Parkinsonism
following moderate or severe TBI;

(ii) Unprovoked
seizures following moderate or severe TBI;

(iii) Dementias
(presenile dementia of the Alzheimer type and post-traumatic
dementia) if manifest within 15 years following moderate or severe
TBI;

(iv) Depression if
manifest within 3 years of moderate or severe TBI, or within 12
months of mild TBI; or

(v)Diseases of
hormone deficiency that result from hypothalamo-pituitary changes
if manifest within 12 months of moderate or
severe TBI.

If you have any of these five conditions,
you should file a claim for it as secondary to your TBI.
However, it is probably best to wait until after your TBI is
service-connected. If it is already service-connected, you may
file a claim on the secondary conditions now.

If the VA denies your claim for one of these
secondary conditions (or already denied it in the past), and the
proposed regulations are later finalized and approved, you may then
re-open your claim on the basis of the new regulation. If you
re-open the claim within six months of the rule change, the VA may
grant benefits going back to the date the new regulations take
effect.

Establishing your claim

TBI is one of the easiest claims to
establish, and the secondary conditions have strong research to
back up your claim when you get to that point. Work with your
Veterans Service Organization Representative (VSO Rep) to make sure
you have a fully developed claim before you submit it. You need to
establish the following:

An
'impact event' during military service when the TBI occurred

A
diagnosis of TBI with medical documentation of the symptoms and
severity

Lay
evidence to provide additional documentation of symptoms

If
claiming a secondary condition, for now, make sure to get
an 'as likely as not' doctor's letter

If you have trouble convincing your doctor,
please contact the NGWRC so we may help you get the IOM
conclusions supporting your claim to your doctor. That may help
convince him or her of the validity of your claim for a secondary
condition.

Once your claim is established and developed,
your VSO Rep will submit it on your behalf. If you have a TBI
claim, it is important to establish the TBI first, before you go on
to secondaries to TBI or to a claim for PTSD.

CHAPTER
VII – Post-Traumatic Stress Disorder (PTSD)

Introduction

What is PTSD?

History of the
PTSD diagnosis

Who is eligible to
receive benefits for PTSD?

Building a VA
claim for benefits

Establish an
in-service stressor

Evidence to
establish a stressor of in-service personal assault

Establish PTSD
diagnosis and link it to your stressor

Re-opening PTSD
Claims

VA Medical
Services

Introduction

The way in which
the VA and the mental health care community at large diagnoses and
treats PTSD has changed significantly since the start of recent
military operations, such as OIF and OEF. If you have PTSD, and
you were denied benefits before July of 2010, you may wish to
re-open your claim.

It is easier to
prove any claim for PTSD than it used to be. Above and beyond
that, the VA is now more likely to give the benefit of the doubt to
the veteran in the case of PTSD caused by sexual trauma in the
military.

What
is PTSD?

The Fifth Edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), released on May 18, 2013 revised the criteria for
diagnosing Post-Traumatic Stress Disorder. The DSM-5 criteria
follow.

There must be an
identified trigger to PTSD. The trigger (the VA uses the word stressor instead of the word trigger in its regulations) is
exposure to actual or threatened death, serious injury or
sexual violation. The exposure must result from one or more of
the following scenarios, in which the individual:

directly
experiences the traumatic event;

witnesses
the traumatic event in person;

learns
that the traumatic event occurred to a close family member or
close friend (with the actual or threatened death being either
violent or accidental); or

experiences
first-hand repeated or extreme exposure to aversive details of the
traumatic event (not through media, pictures, television or movies
unless work-related).

The disturbance,
regardless of its trigger, causes clinically significant distress
or impairment in the individual’s social interactions,
capacity to work or other important areas of functioning. It is not
the physiological result of another medical condition, medication,
drugs or alcohol.

After establishing
a trigger, diagnosis depends on identifying behavioral symptoms
that accompany PTSD in one or more of four diagnostic clusters –
re-experiencing, avoidance, negative cognitions and mood, and
arousal.

Negativecognitions and mood represents myriad feelings, from a
persistent and distorted sense of blame of self or others, to
estrangement from others or markedly diminished interest in
activities, to an inability to remember key aspects of the event.

Arousal is marked by aggressive, reckless or self-destructive behavior,
sleep disturbances, hyper-vigilance or related problems. The
'flight' aspect is included in this cluster.

The disturbance,
as measured by the symptoms above, must persist for one month
before it may be diagnosed as PTSD. There is no distinction
between acute and chronic phases of PTSD.

At the time of
this writing, the VA has not had time to make any changes to its
internal definition of PTSD since the DSM-5 was released. Some
research used to revise the DSM was accounted for by the VA in
2010, when it made several changes that help veterans with PTSD.

History
of the diagnosis “Post-traumatic Stress
Disorder”

PTSD
is not a new problem. It was around before humans developed speech.
Written records from ancient Egypt, Greece, and Rome detail
symptoms of PTSD occurring in battle veterans. We have used
different names for it at different times in our history. In
American history, it was previously referred to as “shell-shock”
and “war/combat neurosis”. PTSD occurs in veterans of
all wars and eras and in non-veterans exposed to traumatic events.
Similar long-term responses to traumatic events occur in certain
non-human creatures, including some of our pets.

In 1980, the American
Psychiatric Association (APA) created the diagnosis PTSD when it
published the DSM-III. Our understanding of PTSD continues to
expand with new research and treatments; the definition, diagnostic
criteria, and VA rules around it continue to change over time.
This guide provides the most current information available, as it
pertains to a claim for benefits, as of May 31, 2013. Any new
revisions to VA guidelines will be posted by the VA on their
website, www.va.gov.
We also discuss changes on our own website, www.ngwrc.org.

The APA diagnostic criteria for
PTSD changed with each revision to the DSM since 1980, being
revised in DSM-III-R (1987), DSM-IV (1994), DSM-IV-TR (2000), and
DSM-5 (2013). For a more
thorough overview of PTSD as it relates to veterans, please refer
to the VA history and overview at
http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp.

Who
is eligible to receive benefits for PTSD?

A claim for PTSD is not limited
to veterans who participated in combat with the enemy. Some
in-service stressors that are recognized by the VA include:

Military
Combat

Sexual
Assault

Other
Personal Assault

Vehicular
Accident

Being
the Victim of a Crime

Other sufficiently traumatic
events during service can support a diagnosis of PTSD for VA claims
purposes. Merely being in stressful situations, or being
“stressed-out” generally will not be sufficient.

Building
a VA benefits claim for PTSD

The VA requires
three components be proven in order to establish a
service-connected rating for PTSD, outlined in CFR 38 §3.304(f).

This
is much easier for veterans today than it once was. Here is a
simplified summary of the sub-paragraphs of CFR
38 §3.304(f) which make is easier to establish your claim.
You may find the full regulation in the appendices. The numbers
here match with the numbers in CFR 38 §3.304(f):

(1)
If you are diagnosed
with PTSD while you
are still in the
military, your lay
testimony alone is usually sufficient evidence of a stressor as
long as your claim is consistent with
the circumstances, conditions, or hardships of your service.

(2)
If your military
records show you
engaged in combat with
the enemy, and you are
diagnosed with PTSD after you are discharged, your lay
testimony alone may establish the claimed in-service stressor.

(3)
If your claimed stressor is the fear
of hostile
military or terrorist activity,
and a VA psychiatrist
or psychologist agrees that your stressor is adequate to support
your PTSD diagnosis; that may be accepted as the stressor.

(4) If you have evidence that
you were a prisoner-of-war, then your lay testimony alone may be
sufficient evidence of a stressor.

(5)
If your claimed stressor is an in-service
personal assault, including sexual assault or rape,
evidence other than your
service records may corroborate your account of the stressor
incident.

A
combat-related military occupational specialty (MOS) or
combat-related awards or decorations (e.g.,
a Combat Infantryman’s Badge or a Purple Heart) are examples
of documented combat experience. However,
if your service records do not demonstrate a combat-related MOS or
decorations and you assert that you have experienced combat, enemy
fire or attack, the VA is required to assist you in obtaining
documentation that supports your claim (including researching
government records) that could place you in a documented area of
attack or an isolated hostile incident.

If
the claimed stressor is not
related to combat or POW status,
the veteran must prove its existence with evidence, such as service
medical or personnel records, unit records, morning reports, or
buddy statements. The VA allows a broad range of evidence as proof
of a stressor for trigger events which the military has a history
of leaving off its records, such as in-service rapes, sexual
assaults, and other personal assaults.

If
your claimed stressor is rape,
sexual assault,
or any other in-service personal assault, here are examples of
records you may use to corroborate your account.

pregnancy tests or tests for
sexually transmitted diseases

records from:

law enforcement authorities

rape crisis centers

mental health counseling
centers

hospitals

physicians

statements from:

family members

roommates

fellow service members

clergy

As
you obtain statements, keep in mind that the VA accepts evidence
of behavior changes
following the claimed assault as one type of relevant evidence that
may be found in these sources. Examples of behavior changes that
may constitute credible evidence of the stressor include:

a request for a transfer to
another military duty assignment

deterioration in work
performance

substance abuse

episodes of depression, panic
attacks, or anxiety without an identifiable cause

unexplained economic or social
behavior changes.

The
statements need to show
change in your
behavior. If you were a heavy drinker both before and after the
stressor, the fact that you continued to drink is not a change.

The VA may submit any evidence
that it receives to an appropriate medical or mental health
professional for an opinion as to whether it indicates that a
personal assault occurred.

Establish
PTSD diagnosis and link it to your stressor

A PTSD diagnosis must come from
a psychiatrist or psychologist. Your VA doctor can refer you to
one of these specialists to confirm your symptoms and diagnose you
with PTSD if you do not yet have that established.

If you have records that
document the in-service stressor, let your doctor review them prior
to writing his or her report. It is even better to provide your
doctor with a copy of your service medical records. If parts of
your psychiatric records were redacted, your doctor may be able to
obtain those records to help with diagnosis and treatment; however,
they may be unable to share those redacted records with you.

Veterans with PTSD may have
other diagnoses in areas of mental health and substance abuse,
e.g., personality disorder or alcoholism. It is very
important that your doctor explain how your current diagnosis of
PTSD relates to any other psychiatric disorder that you might have.
If there is a history of alcohol or drug abuse, the doctor should
state whether it preexisted PTSD or not and whether substance abuse
developed because of PTSD (i.e., self-medication).

You can expect the VA to
contact you for evidence or for permission to request copies of
your medical records. If the VA has treated you for your PTSD,
make sure to ask that the VA obtain all records from the treatment
center.

The VA may schedule you for an
examination by one of its doctors at a VA hospital or clinic. This
examination (called a compensation and pension examination [C&P
exam]) is intended to confirm a diagnosis of PTSD and, if present,
to describe the nature and severity of its symptoms. Bring copies
of any prior psychiatric treatment records to the examination with
you. If you do not have records of recent treatment for PTSD, you
may specifically request that the VA provide you with a C&P
exam.

If you do not already have a
private doctor's report, you should expect the VA doctor to ask
many questions about what symptoms you have, when you began to have
them, and how often and how long you have had them. Some of the
hardest questions will be about the stressful experience you had.
You will need to be able to describe in detail (and sometimes
painful detail) exactly what you experienced. You might also be
asked to take a written, standardized diagnostic test.

Once you prove evidence of an
in-service trigger event, and you are diagnosed with PTSD after the
event, the VA is likely to link the two together unless there is
other evidence specifically suggesting that your particular case of
PTSD was triggered by some event outside of your military service.

It is possible to experience
PTSD from multiple triggers both in and out of service. If you
have symptoms and experience that match up with your in-service
stressor, you should pursue your claim – the VA can
legitimately rate you as service-connected and assign benefits to
you even if there are additional trigger events besides those in
the military.

Re-opening
PTSD Claims

What
if your claim for PTSD was denied on or before July, 2010?

If
you were denied compensation on a claim for PTSD before the most
recent change in VA rules, July, 2010, you are permitted to request
that your previously denied claim for PTSD be reopened and
reevaluated based on the VA's new criteria. You may send a letter
to your VA Regional Office asking to have your previously denied
claim reevaluated under the new regulations.

This
rule change, or any change in the regulations for disability
compensation under a specific diagnosis, allows you to re-open a
claim without presenting “new and material evidence”.
If you are awarded benefits under these circumstances, they will go
back to the date on which the VA receives your request to re-open
the claim.

There
was a window in which re-opened claims could be granted back to the
date on which the new rule took effect, rather than the date the
claim was re-opened. However, that window was six months, ending
in January, 2011.

If
you believe you have new and material evidence to reopen a PTSD
claim denied after July, 2010, consult with your VSO Rep.

VA
Medical Services

The
VA operates a network of Vet Centers throughout the country that
provides treatment for veterans suffering from PTSD. Treatment at
Vet Centers is often conducted with a group of veterans. Sometimes
the VA will pay for treatment by a local mental health
professional, if services through the nearest VA are not readily
available. To apply for this "fee basis" care, contact
your nearest VA medical center.

There
are also a few VA medical centers that offer intensive inpatient
care. If this is something you need, ask the nearest Vet Center to
help arrange for your admission.

Amyotrophic Lateral
Sclerosis (ALS), or
Lou Gehrig’s disease, kills cells in the brain and
spinal cord that control muscle movement, resulting in gradual
wasting of the muscles. Fatal in most cases, the disease usually
strikes people between ages 40 and 70. The cause of the disease is
unknown. ALS does not affect the senses (sight, smell, taste,
hearing, touch), bladder or bowel function, or a person's ability
to think or reason.

Who
may claim service-connection for ALS?

Under
most circumstances, if you are a US military veteran diagnosed with
ALS, it will be presumptively
service-connected. All you
need to do is file the claim. The claim will be expedited because
ALS is a terminal illness.

Here is the exact
language of CFR 38, §3.318(a):

Except as provided
in paragraph (b) of this section, the development of amyotrophic
lateral sclerosis manifested at any time after discharge or release
from active military, naval, or air service is sufficient to
establish service connection for that disease.

The full section
is reprinted in the appendices if you want to look up the
exceptions.

Symptoms

Difficulty
breathing

Difficulty
swallowing

Gagging

Chokes
easily

Head
drop due to weak spinal and neck muscles

Muscle
cramps

Muscle
weakness that slowly gets worse

Commonly
involves one part of the body first, such as the arm or hand

Eventually
leads to difficulty lifting, climbing stairs, and walking

Paralysis

Speech
problems, such as a slow or abnormal speech pattern

Voice
changes, hoarseness

Additional
symptoms that may be associated with this disease:

Drooling

Muscle
contractions

Muscle
spasms

Ankle,
feet, and leg swelling

Weight
loss

The VA established
a national ALS registry to identify veterans with the disease --
regardless of when they served -- and track their health status.
Veterans with ALS who enroll will complete an initial telephone
interview covering their health and military service and will be
interviewed twice yearly thereafter. For more information about
the VA’s ALS Registry, based at the Durham VA Medical Center,
call 1-877-DIAL-ALS (1-877-342-5257) or e-mail ALS@med.va.gov

More
Information on ALS

The
following organizations support research and in some cases can
provide information and support for patients and their families.

There
is no presumptive service connection to cancer for most veterans of
post-Vietnam conflicts. If you have a cancer which you believe is
related to your military service, but you do not meet the
definition of an Agent Orange or Radiation-Exposed Veteran, then
you will have the standard burden of proof applied to your claim.
You must provide a medical opinion from a doctor stating it is 'at
least as likely as not' that your current cancer is related to your
claimed in-service exposure.

This
may require extensive research to prove your exposure and to back
up your doctor's claim of the relationship. Presenting strong
evidence of the relationship to your doctor is, in fact, what can
make the difference in whether or not that doctor will write the
letter for you. Some doctors are not up-to-date on research
showing the relationship between a particular exposure and a
particular cancer.

Depleted
Uranium & Cancer for SWAT veterans

Depleted
Uranium (DU) is a mildly radioactive heavy metal that, like lead
and mercury, is highly toxic when inhaled or ingested. Its
long-term effects remain a subject of debate.

No cancers
are presumptive for Iraq, Persian Gulf, or other recent
(1990-current) conflict veterans on the basis of their foreign
deployments, but the VA does grant service connection on a
case-by-case basis. The VA realizes that cancers take decades to
manifest - there is no '1 year limit' on symptoms for cancer.

DU is
recognized as a possible cause or accelerator of cancer, but the
evidence is not yet strong enough to make it presumptive. If a
veteran can both make a case that he or she has high exposure to
it, such as DU shrapnel fragments in his or her body, and get a
doctor's 'as likely as not' statement in support of claim, the
veteran may file with a reasonable chance of success.

Agent
Orange and other Herbicides [CFR 38
§3.309(e)]

Agent
Orange and other herbicides used by the military during the 1960's
and 1970's are known to cause an increased risk of several cancers.
As a result of this, if you develop one of those cancers later in
life, it will be presumed as related to your military service, if
one of the following applies to you:

Consult
your VSO Rep if you want to consider filing a claim for any of
these illnesses with presumptive service-connection as an Agent
Orange Veteran.

Ionizing
Radiation [CFR 38 §3.309(d)]

Certain
veterans are granted presumptive service-connection for several
cancers and other diseases which may be related to their exposure
to ionizing radiation from a nuclear detonation or at a gaseous
diffusion plant.

The
VA grants presumptive service connection for 21 types of cancer to
certain radiation-exposed veterans. The presumption is
limited to very specific groups of veterans, and it is not related
to service in any combat-related or occupation-related operation
which occurred after July 1, 1946. However, veterans who served on
the grounds of a gaseous
diffusion plant located in Paducah, Kentucky, Portsmouth, Ohio, or
the area identified as K25 at Oak Ridge, Tennessee, as recently as
1992 may be presumptively service connected for any of the 21
cancers.

Here
is a summary what may qualify a veteran to be considered radiation-exposed by the VA:

Onsite
participation in a test involving the atmospheric (or underwater)
detonation of a nuclear device.

The
occupation of Hiroshima or Nagasaki, Japan, by United States
forces during the period beginning on August 6, 1945, and ending
on July 1, 1946.

Internment
as a prisoner of war in Japan during World War II in a location
which resulted in an opportunity for exposure to ionizing
radiation between August 6, 1945 and July 1, 1946.

Service
as part of official military duties of at least 250 days before
February 1, 1992, on the grounds of a gaseous diffusion plant
located in Paducah, Kentucky, Portsmouth, Ohio, or the area
identified as K25 at Oak Ridge, Tennessee.

Service
before January 1, 1974, on Amchitka Island, Alaska, with possible
ionizing radiation exposure in the performance of duty related to
the Long Shot, Milrow, or Cannikin underground nuclear tests.

If
you believe you are affected, please read the full section of CFR
38, §3.309(d) in the appendices and consult your VSO Rep.

You
are required to have an attorney to bring your case before the
Court of Veterans Appeals or to a higher court. You may choose to
use an attorney for other stages of your claim. Attorneys may
charge a contingency fee plus expenses for their services.

1. Advocate
tirelessly for veterans from SWA issues - We will promote media
awareness and Congressional investigations to ensure that
Department of Veterans Affairs (VA) Gulf War review efforts are
comprehensive, correct and supportive of the SWA veteran.

2. Provide
educational material and assistance to SWA Veterans and their
families - We are committed to helping veterans improve their
chances of receiving overdue compensation for their
service-connected illnesses. A key component of that commitment is
producing and updating a Self Help Guide that covers important
topics such as medical research and legislative developments,
organizations that support veterans of SWA, lessons learned, and
assistance available from federal agencies such as the Department
of Veterans Affairs.

3. Educate VA,
legislators and medical facilities on the complexities of Gulf War
Illnesses - We serve the veteran by informing legislators of
provisions needed to protect, treat and compensate SWA Veterans,
and we educate medical providers on the wide variety of symptoms
and illnesses faced by SWA veterans.

4.
Create a diverse, dynamic organization membership dedicated to
vital veteran issues - Gulf War Illness issues affect veteran,
scientific, legal, family, and other constituents, as well as
current and future service members. To ensure adequate involvement
and to prevent repetition of past mistakes, NGWRC solicits from all
interested communities and constantly updates its website with
relevant and useful information.

5.
Review and analyze all relevant government and industry actions,
policies, research efforts, and writings concerning Gulf War Era
and future veterans' issues - We are committed to being a leader in
understanding the complexities of Gulf War Illnesses
by evaluating new concepts in treatment through collaborations with
and our organizational presence at the Department of Veterans
Affairs Research Advisory Committee meetings. We will continue to
create and implement progressive policies that maximize results for
the veterans, increase public understanding, help create clear
understanding of illness issues, and ensure the protection of
future veterans.

6.
Furthering comradeship amongst those who are or have been members
of the Armed Forces of the United States -
The
NGWRC has done much to bring Gulf War issues before Congress and
the media, exposing Pentagon and VA policies that have severely
impacted veterans and their families. Our most valuable efforts
have resulted in legislation that required research and
service-connected disabilities for certain conditions associated
with Gulf War service. NGWRC does this with the grants and donation
we receive from individual and foundations.

Appendix II - Exposures

Chemical
Warfare Agents 59

Status of
Investigations and Epidemiological Research 60

Investigational
Drugs 63

Pyridostigmine
Bromide (PB) 64

Botulinum
Toxoid (BT) Vaccine 65

Anthrax
65

Depleted
Uranium (DU) 69

Veterans
serving in the Iraq, the Persian Gulf, and elsewhere in the
Southwest Asia Theater between 1990 and the present day were
exposed to a wide range of agents which may contribute to long term
illness. These exposures include:

Type
of Exposure

Oil Well
Fires and Smoke

Pesticides

Depleted
Uranium (DU)

Infectious
Diseases

Anthrax
Vaccine

Sand and
Particulate Matter

Vaccine
Adjuvants

Petro
Chemicals and Solvents

Botulinum
Toxoid Vaccine

Vehicle and
Aircraft Fuels

Multiple
Vaccines

Chemical
Resistant Coating Paint

Pyridostigmine
Bromide (PB) Pills

Contaminated
Food and Water

Chemical
Warfare Agents

Chemical Warfare
Agents

Historical
Perspective: The NGWRC, our member groups, and many individual
veterans uncovered numerous documented chemical incidents and
casualties using the Congressional reports, the Freedom of
Information Act (FOIA), and information provided to us from
individual veterans. As a result, by 1997, the DoD was forced to
admit that 100,000 U.S. troops were exposed to low levels of sarin,
cyclosarin, and mustard agents during the demolition of an Iraqi
military bunker complex at the Kamisiyah depot in March 1991. In
1999, the VA increased the number to more than 124,000 and
eventually to over 140,000 U.S. troops exposed. A much clearer
picture emerged, in part at least because NGWRC exposed DoD
statistical manipulations that demonstrated flawed modeling and
understanding of the estimated exposures.

NGWRC’s
research campaign resulted in the DoD revamping their entire Gulf
War Illnesses investigation. By 1999, the DoD employed a staff of
more than 150 to investigate the thousands of toxic exposure
incidents, many brought to light by NGWRC research volunteers.
Official military documents obtained from Congressional reports,
using FOIA, or letters sent by Gulf War veterans have revealed the
following:

The
U.S. Departments of State, Defense, and Commerce allowed the
shipment of dual-use chemical precursors and technology to Iraq
until 1990.

Possible
offensive use of chemical warfare agents by Iraq against Israel,
according to Central Command Nuclear, Biological, and Chemical
(CENTCOM NBC log) incident logs compiled between January and March
1991.

Possible
deployment of chemical warfare agent land mines by Iraq, according
to CENTCOM NBC log.

Exposure
of Coalition troops and civilians to chemicals due to Coalition
bombings of Iraqi manufacturing and storage facilities during the
air war, according to a report and Senate investigation led by
former Senator Donald Riegle.

Exposure
of troops to chemicals from artillery and other bombardment and/or
exposure of troops to chemicals as a result of post-cease fire
demolitions, according to the CENTCOM NBC log.

In
spite of the overwhelming evidence of widespread poisonous gas
exposures, the DoD continued to downplay the seriousness of these
exposures. Documented evidence suggests the Pentagon possessed
prior knowledge, before the air war, of the potential for chemical
releases and the subsequent health problems that could be caused by
exposure to low level chemical warfare agents, according to a
report prepared by the Lawrence Livermore Laboratory in California.

Also,
part of the problem in dealing with chemical exposures is the DoD’s
misguided doctrine that in order to confirm exposure, a soldier
must experience visible and severe effects (such as death)
immediately following exposure.

In
1996, the NGWRC called for the appointment of a special prosecutor
from the Department of Justice to investigate the misplacement,
concealment, or destruction of government documents related to
chemical and biological agent incidents and exposures. As a result
of this request, DoD's IG investigated the missing chemical
exposure documents and determined they were accidentally destroyed
by a computer virus on an unauthorized video game on a DoD
computer, lost from at least two locked military safes, and/or
still classified.

As
of this writing, Representative Rush Holt (D-NJ) continues to push
for DoD’s declassification of the remaining documents that
the CIA and DoD didn't lose or shred.

As
a result of NGWRC’s work in documenting known exposures and
pushing for research demonstrating the health effects of low level
exposures, DoD has funded some medical research projects in this
area and has also begun reevaluating their low-level chemical
exposure doctrine.

Status of
Investigations and Epidemiological Research

Numerous
studies have essentially disproved the DoD notion that only
immediately visible, severe symptoms provide evidence of exposure
to chemical agents. According to a study by researchers at the
University of New Mexico, Albuquerque, and the U.S. Army Medical
Research Institute of Chemical Defense, Aberdeen, MD, exposure to
sarin nerve gas in concentrations too low to produce immediate
symptoms causes irreversible brain damage in laboratory rats.

Publications

The
findings, published in three scientific articles in the journal Toxicology and Applied Pharmacology supply missing pieces
that connect nerve gas exposure in the 1991 Gulf War to memory
loss/cognitive dysfunction, weakened immune response, and DNA and
behavior abnormalities.

Gulf
War Illnesses: Preliminary Assessment of DoD’s Plume
Modeling for U.S. Troops’ Exposure to Chemical Agents, by
Keith A. Rhodes, chief technologist, before the Subcommittee on
National Security, Emerging Threats, and International Relations,
House Committee on Government Reform; http://www.gao.gov/new.items/d03833t.pdf

The
number of U.S. troops exposed to nerve gas after the first gulf war
was underestimated because of flaws in how troops were studied,
government investigators have concluded.

The
computer models used to determine the extent of sarin gas exposure
were inaccurate and incomplete. Troops were exposed to sarin, a
toxic nerve agent, when a missile arsenal at Kamisiyah in
southeastern Iraq was blown up in March 1991.

Over
the years, the military has raised its estimate of the number of
exposed troops from a few hundred to more than 100,000. Now the
General Accounting Office (GAO) says the estimate is inadequate.

In
June of 2004 the GAO told a congressional panel that the computer
models, developed by the DOD and the CIA, did not take weather
patterns into account, The models also underestimated the height of
the plumes sent skyward when the arsenal was destroyed. Defense
and CIA modeling underestimated the extent of U.S. troop exposure
since the modeling was not accurate enough to draw conclusions.

In
1998, the IOM began a series of congressionally-mandated studies to
examine the scientific and medical literature on the potential
health effects of chemical and biological agents related to the
1991 Gulf War. The studies completed to date are listed at the
above IOM web link.

The
first study reviewed the scientific literature on depleted uranium,
chemical warfare agents (sarin and cyclosarin), pyridostigmine
bromide, and vaccines (anthrax and botulinum toxoid) and resulted
in the report, Gulf War and Health Volumes 1: Depleted Uranium,
Pyridostigimine Bromide, Sarin, and Vaccines.

In
February 2001, the IOM convened a subsequent committee, to examine
the health effects associated with exposure to pesticides and
solvents. This study resulted in the report Gulf War and
Health: Volume 2: Insecticides and Solvents.

In
March 2003, a third committee was convened to conduct a review of
the peer-reviewed literature on the long-term human health effects
associated with exposure to selected environmental agents,
pollutants, and synthetic chemical compounds believed to have been
present during the 1991 Gulf War including hydrazines, red fuming
nitric acid, hydrogen sulfide, oil-fire byproducts, diesel-heater
fumes, and fuels (for example, jet fuel and gasoline). This study
resulted in the report Gulf War and Health, Volume 3: Fuels,
Combustion Products, and Propellants.

In
January 2005, a fourth committee was convened to review, evaluate,
and summarize peer-reviewed scientific and medical literature
addressing the overall health status of Gulf War veterans to see
what this literature collectively shows about the prevalence of
veterans’ symptoms and illnesses. This study resulted in the
report Gulf War and Health, Volume 4: Health Effects of Serving
in the Gulf War.

In
March 2005, the IOM convened a fifth committee to review, evaluate,
and summarize the peer-reviewed scientific and medical literature
on long-term adverse human health effects associated with selected
infectious diseases (such as diseases caused by pathogenic
Escherichia coli, shigellosis, Leishmaniasis, and sandfly fever)
pertinent to Gulf War veterans, as well as to veterans of the
current conflicts (Operation Iraqi Freedom; Operation Enduring
Freedom). This study resulted in the report Gulf War and
Health, Volume 5: Infectious Diseases.

In
May of 2005, a sixth committee was convened to comprehensively
review, evaluate, and summarize the peer-reviewed scientific and
medical literature regarding the association between stress and
long-term adverse health effects (physiological, psychological, and
psychosocial) in Gulf War veterans. This study’s findings
are not only limited to veterans of the 1991 Gulf War conflict but
are applicable to veterans of the current conflict (Operation Iraqi
Freedom; Operation Enduring Freedom). Gulf
War Health, Volume 6: Gulf
War and Health: Physiologic, Psychologic, and Psychosocial Effects
of Deployment Related Stress.

The
VA, under authorization granted in the 1998 legislation, has asked
IOM to determine long term health outcomes associated with TBI.
TBI has been called the signature injury of OEF and OIF primarily
due to blast exposure that is characteristic of this conflict.
Exposure to blast might cause instant death, injuries with
immediate manifestation of symptoms, or injuries with delayed
manifestation. Blast-induced neurotrauma, however, has not been
studied sufficiently to confirm reports of long-term effects. That
many returning veterans have TBI will likely mean long-term
challenges for them and their family members. Veterans will need
support systems at home and in their communities to assist them in
coping with the long-term sequelae of their injuries. Further, many
veterans will have undiagnosed brain injury because not all TBIs
have immediately recognized effects or are easily diagnosed with
neuroimaging techniques. In 2008 the
report, Gulf
War and Health, Volume 7: Long-term Consequences of Traumatic Brain
Injurywas
released.

In
April of 2010 the IOM released a new report, this one indicating
that Gulf War service was linked to
Post-Traumatic Stress Disorder (PTSD), Multi-symptom illness, and
other health problems, but that the
causes still remain unclear. Their report is entitled: Gulf
War and Health, Volume 8: Health Effects of Serving in the Gulf
War.

Research
Advisory Committee on Gulf War Veterans’ Illnesses
(RAC-GWVI)

The
Research Advisory Committee on Gulf War Veterans' Illnesses was
created by Congress in 1998, and first appointed by Secretary of
Veterans Affairs Anthony J. Principi in January, 2002. The
mission of the Committee is to make recommendations to the
Secretary of Veterans Affairs on government research relating to
the health consequences of military service in the Southwest Asia
theater of operations during the Persian Gulf War.

In
November of 2008 the RAC-GWVI published “Gulf War Illness
and the Health of Gulf War Veterans”. This publication
can be viewed in its entirety at the above web link. NGWRC highly
recommends that all Gulf War veterans take the time to familiarize
themselves with the myriad of information contained in this very
detailed publication.

Investigational
Drugs

In
December 1990, the Food and Drug Administration (FDA) issued a
waiver to the DOD allowing the military to administer
“investigational new drugs” to U.S. troops without
obtaining informed consent. The NGWRC understands the intent of
the DOD to provide the best possible protection to U.S. troops
deployed overseas. However, the NGWRC filed suit to require the
DOD to follow other U.S. laws and the Nuremberg Code. Both require
informed consent from the patient before an IND is used.

Informed
consent means telling the soldiers what they are getting, why they
are getting it, maintaining adequate records, and providing any
needed medical care resulting from use. On October 17, 1998 PL
105-261 was enacted, requiring the president of the United States
to issue a Finding before any INDs are used on military personnel.
Thus, PB and BT could not be used without significant executive
branch endeavor to meet legal conditions. Unfortunately, this
NGWRC, veteran and service member victory has been virtually
nullified by several developments. President Clinton issued
Executive order 13139 in 1999 that allowed him and his successors
to waive informed consent in times of nation security emergency.
Additionally, the FDA instituted an “animal only” rule
for bio-warfare drugs and vaccines that circumvented the
long-standing requirement for human efficacy testing on the basis
that such testing is unethical. Furthermore, the FDA is now
differentially licensing drugs and vaccines for service-members and
civilians (smallpox vaccine and PB are now fully licensed for
wartime use but civilians are receiving smallpox vaccine under an
IND). Upon determination by the president, at the request of the
Secretary of Defense, and because of the FDA ruling, service
members now face the exact same problem of forced experimentation
experienced by Gulf War veterans.

Pyridostigmine
Bromide (PB)

Historical
Perspective

Pyridostigmine
bromide (PB), a nerve agent pre-treatment drug, was a small white
pill issued to U.S. and U.K. troops in blister packets. According
to the DOD, as many as 250,000 U.S. troops took PB pills. The DOD
failed to follow the FDA waiver, and very few records exist
documenting who took how many of these pills.

Approved
only for use in cases of a severe neurological disorder known as
myasthenia gravis or to reverse anesthesia, PB has never been
approved for use on civilians to protect against chemical warfare
agents – this is why it has IND status (NO longer IND since
March 2003).

In
the few limited tests conducted prior to the war by the DOD, women,
smokers, and anyone who might be at all sensitive to the drug were
not allowed to participate. Despite screening, some adverse
effects were noted. Some researchers believe pre-treatment with PB
is only effective in relation to exposure to soman and they claim
it may increase adverse effects of sarin.

Status
of Investigations and Epidemiological Research

The
National Gulf War Resource Center has demanded answers from the FDA
concerning the approval of PB as a pretreatment for exposure to the
nerve agent Soman. Documents and scientific studies conducted over
the last 15 years have clearly shown this drug is both experimental
and harmful when used for CW pretreatment, since soldiers are
exposed to pesticides and other substances that increase PB’s
toxicity. The DOD and the Department of Veterans Affairs have both
concluded through previous studies that PB could not be ruled out
as a factor in Gulf War veteran’s illnesses. In fact,
Congress banned DOD’s use of the substance in an amendment to
the FY ’99 Defense Authorization Bill unless it was approved
for use by a Presidential waiver.

Several
problems persist for continued use of this substance:

Studies
have shown that PB’s effectiveness against Soman is
questionable; more importantly, our enemies in Iraq and
Afghanistan have never been shown to have stores of Soman.
Prescribing PB as a pretreatment is unscientific, dangerous, and
appears to be simply a CYA maneuver in the event other measures,
such as personal protective equipment, fail and is not proven
effective by scientific fact.

PB’s
dosing for effectiveness is variable in each individual and would
require individual evaluation due to the genetics and the size of
the person receiving the dose.

PB
is known to cause muscle damage in the animal studies cited by the
FDA with even one dose.

Researchers
have shown that PB, with simultaneous exposures to combinations of
DEET, permethrin, sarin, or jet fuel, causes brain and testicular
injury in experimental animals.

Thus,
in allowing its use the FDA, DOD, Congress and the President are
permitting questionable protection against Soman and increasing the
likelihood that troops will be more susceptible to Sarin. It is
possible that those who made the decision think they have chosen
the lesser of two evils with the troops’ protection in mind.
But a policy decision that ignores the facts about the risks of PB
is irresponsible policy-making.

It
is unfortunate that the FDA has approved PB when it is known to
have harmed veterans of the last Gulf War. Once again, our
government is putting soldiers in another type of “Harm’s
Way,” which could have been prevented. FDA’s ruling is
most likely the impetus for soldiers saving their sperm prior to
the latest deployment to the Gulf region. The very least the
Pentagon should have done is to give pre- and post-deployment exams
and blood draws that may allow for analysis of PB effects on
health.

Botulinum
Toxoid (BT) Vaccine

The
botulinum toxoid (BT) vaccine is also an IND. Before the 1991 war
began, Ralph Nader’s Public Citizen sought a court order to
prevent the military from using the anti-nerve agent pill and
botulinum toxoid vaccine. According to the DOD, approximately
8,000 U.S. troops received this vaccine. Again, the DOD failed to
comply with the FDA waiver, and few records were kept showing who
received the BT vaccine. An amendment by Senator Byrd of West
Virginia to the FY 1999 Department of Defense Authorization Bill
required the military to stop using this vaccine, along with the PB
Tabs, without a waiver of informed consent by the President. The
NGWRC is not aware of any research underway or completed regarding
the long-term effects of the BT vaccine.

Military
Perspective – First known use of Anthrax as a
biological weapon was against the Chinese by the occupying Japanese
army in the 1930s. In response, the United States, Canada and the
United Kingdom developed and experimented with anthrax weapons in
1941. After signing the Biological and Toxic Weapons Convention in
1972, the US stopped development of anthrax weapons.

The
Vaccine: Although some form of Anthrax vaccine has been
used since 1881, when Louis Pasteur developed the first successful
vaccine for veterinary purposes, there are still many questions and
problems about its use:

Several
formulations have been developed; some have proved fatal to
recipients, others ineffective at preventing disease.

The
anthrax vaccine approved by the FDA is only for skin-contact
(cutaneous) exposure; inhalation and ingestion exposures remain
unprotected. Ingestion anthrax is rare, but inhalation anthrax
seems like a more logical delivery for a bioterrorist to use than
cutaneous delivery. The FDA eventually approved the same vaccine
for all forms of anthrax, leaving many to doubt the entire process
of FDA approval.

For
the 150,000 troops who were inoculated against anthrax in 1990-91,
records kept by the DOD were incomplete and inconsistent.
Therefore, there is no record to show who received the DOD
vaccine, when it was given, or which lots of vaccines were used.
According to the DOD, records were not kept due to a mistaken
belief by some military healthcare providers that the anthrax
vaccine was a classified matter.

Some
lots of the vaccine may have been contaminated.

Some
shot recipients did not deploy to the Persian Gulf, but did
develop illnesses similar to other veterans who had shots and
other toxic exposures in theater.

Hundreds
of service personnel have reported adverse reactions, some severe
and life threatening.

There
have been no studies regarding the long-term effects of the
anthrax vaccine.

The
DOD contracts with one company, Emergent BioSolutions, Inc., which
has had issues meeting FDA standards at their production facility.

This
article provides background information on the anthrax vaccine and
the series of ethically-questionable practices by the FDA in
approving and the DOD in using it.

Mandatory
Vaccination: In 1998, DOD made the vaccine program
mandatory for all 2.4 million active duty, reserve, and guard
troops. This program is still highly controversial for the reasons
listed above. From the beginning of the order, military personnel
have refused to take the shots, and many more resigned or retired
rather than face it. For news reports concerning refusals, see:

*editor's
note – the Washington Post link no longer takes you directly
to the article.

Synthetic
Squalene: Another issue that damages DOD's credibility is
the possibility that an experimental delivery vaccine booster
(adjuvant) was used in anthrax vaccines during the Gulf War.
General Accounting Office (GAO) records indicate that the DOD may
have used synthetic squalene in some vaccines, which is not an FDA
approved adjuvant.

Some
Gulf War veterans have long suspected that the use of synthetic
squalene in the anthrax shot is the root cause of their ailments. Dr. Pamela Asa (Tulane University) and her colleagues
created a test to detect antibodies to squalene and discovered that
all sick Gulf War veterans tested had these antibodies; no one in
the control group had the antibodies. GAO reports indicated that
resolution of squalene issues would require cooperation from the
Pentagon, which was not forthcoming. After years of total denial
about squalene, the FDA discovered squalene in all eight anthrax
lots tested in 1999. This information was revealed in a House
Government Reform Committee hearing on 3 October 2000 in a 3-year
report from Representative Metcalf (State of Washington) who was
retiring. The Washington Times weekly news magazine
“Insight on the News” covered the entire history of the
squalene controversy, containing this poignant statement by an
unnamed FDA official: "Something is wrong when we find a
contaminant in the vaccine [lots tested] that shouldn't be there,"
an FDA official tells Insight. "That tells me an investigation
should have been launched. It wasn't, because of pressure, and
that's not right; this vaccine should not be used until DOD finds
out how squalene got into those tested batches, whether other
batches are contaminated and the health consequences from the
contamination."

In
January 2003, anthrax vaccine vials washed up in West Bay, Dorset,
United Kingdom. Suspicions were very strong that deploying British
service members dumped thousands of anthrax vaccine vials overboard
as they proceeded to the current Iraqi conflict. An independent
British lab (SAL) tested some of the vials and discovered the
presence of synthetic squalene. This is considered irrefutable
proof of illegal experimentation on service members by the “chain
of command.” (Gary Matsumoto, “Vaccine
A. The covert government experiment that’s killing our
soldiers and why GI’s are only the first victims”. Basic Books, 2004).

The
current vaccine, according to Matsumoto’s research is
patented to include the squalene adjuvant. NGWRC continues to take
every opportunity to shine light on this vaccine, hoping to attain
recognition, diagnosis, and treatment for Gulf War veterans, and
better force protection for the future.

Reactions:
Following are a few of the more than 2000 documented short term
adverse reactions reported by recipients of the anthrax vaccine to
the FDA’s Vaccine Adverse Event Reporting System (VAERS):

Extreme
fatigue.

Local
pain at injection site with swelling and pain extending
into other body parts.

Muscle
and body weakness.

Dizziness.

Heart
failure.

Nausea
and vomiting.

Fever.

Blurred
vision.

General
malaise.

Documented
long-term side effects reported by some recipients of the anthrax
vaccine include:

Extreme
fatigue.

Concentration
and memory impairment.

Dizziness.

Joint
and muscle pain.

Nausea.

Muscle
and body weakness.

Blurred
vision.

General
Malaise.

Status
of Investigations and Epidemiological Research – On
29 June 2002, the Assistant Secretary of Defense for Health
Affairs, Dr. William Winkenwerder announced the resumption of
mandatory anthrax vaccine shots for service members after a year
hiatus caused by a quarantine of contaminated lots and the
inability of the manufacturer to get FDA licensure for its
facility. After the shots resumed in earnest in November/December
2002, the NGWRC received several calls per week from troops, their
family members, or the media, on the third major military use of
anthrax shots (Anthrax Vaccine Adsorbed, or AVA). This ongoing
issue remains unresolved for many veterans and military personnel.

The following
subtopics report on developments in important areas relevant to
anthrax shot concerns of Gulf War veterans, their families, and
current service members.

Petition
to the FDA:
On October 12, 2001, several key opponents of the Anthrax Vaccine
Immunization Program (AVIP) policy (service members, attorneys and
a retired FDA official) filed a petition with the FDA to declare
the vaccine unsafe, misbranded, or ineffective, as well as
adulterated and experimental given the DOD’s use for
inhalation exposure. Additionally, the petition requested the FDA
enforce its regulations prohibiting distribution of an adulterated
product to government or commercial markets and to revoke the
manufacturer’s license for such violations. http://www.fda.gov/ohrms/dockets/dailys/01/Oct01/101501/cp00001.pdf

In
their October 2002 response to the petition, FDA admitted the
current vaccine’s license is improper and that the FDA had
not enforced its own regulations. In spite of these glaring
admissions, the FDA refused to grant any of the petitioner’s
requests, thus setting the stage for an appeal or action in federal
court, both of which are currently under consideration.

VA
Developments:
On 14 May 2002, the VA General Counsel issued a legal finding
specifically establishing service-connected disability solely for
the anthrax vaccine by redefining the meaning of the word "injury": http://www.va.gov/ogc/docs/2002/PREC_4-2002.doc.

Citation: “If evidence establishes that an individual suffers from a
disabling condition as a result of administration of an anthrax
vaccination during inactive duty training, the individual may be considered disabled by an "injury" incurred during
such training as the term is used in 38 U.S.C. § 101 (24),
which defines "active military, naval, or air service" to
include any period of inactive duty training during which
the individual was disabled or died from an injury incurred or
aggravated in line of duty. Consequently, such an individual may be
found to have incurred disability in active military, naval,
or air service for purposes of disability compensation under 38
U.S.C. § 1110 or 1131.”

A
number of cases involving Gulf War and post-Gulf War veterans are
resulting in award of disability ratings, thus indicating that the
VA is following through on its position.

GAO/Congress:
Dr. Sue Bailey, Assistant Secretary for Health Affairs, Department
of Defense, reported to House Subcommittee on National Security,
Veterans’ Affairs and International Relations of the
Committee on Government Reform, March 24, 1999. Dr. Bailey
subsequently participated in a press conference: http://www.fas.org/spp/starwars/program/news00/t02172000_t0217asd.htm.

Women’s/Birth
Issues: Early in the AVIP program, the Army injected
600 medical workers at its Tripler Army Medical Center in Hawaii
with the anthrax shot. Statistics there showed women experiencing
adverse reactions at twice the rate of men. The Army’s top
immunologist declared at a May 1999 Ft. Detrick meeting that
attendees might regret pushing this vaccine, given the women’s
immune system differences. This warning became reality as the
September 2001 issue of Self magazine documented several
severe cases of women’s reactions.

Depleted
Uranium (DU) is the source of intense controversy. A
radioactive derivative of the process of creating nuclear fuel for
power plants, it is used in weaponry and as a shield on the
exterior of battle tanks. The controversy is between the VA, DOD
and some in the scientific community, who declare that DU is safe
to use and economically sound -- and a few vocal advocates stating
that DU is hazardous, toxic, and environmentally disastrous. We
will attempt to present information that will help veterans decide
which side they believe.

The
U.S. government has stated that exposure to .01
gram in one YEAR can cause health problems:

The
Army accepts the Nuclear Regulatory Commission's (NRC's)
recommended limit of 100 mrem (0.1 rem) per year as the allowed
limit on radiation exposure for its tank crews and maintenance
personnel. The current exposure limits is specified by the NRC at
10 CFR 20.1301. The Army must assure that individual crew members
are not exposed to radiation fields in excess 0.1 rem in any one
year (Source – Federal
Register, July 14, 1998). Editor's
note – source for mrem/hour limit could not be located; that
part of the sentence was removed 2013-jun-27.

However,
a GulfLink website states the following: "Fortunately, it's
really impossible to breathe in enough depleted uranium to do you
any serious harm," [Naomi H.] Harley says. "If you work
in an industry that uses uranium, you're allowed concentrations in
the air of 0.2 of a milligram per cubic meter, which means in a
work day you might inhale two milligrams. This is the kind of air
concentration you find right near [an armored vehicle] where a DU
round hits it. When you breathe it in, you breathe in some uranium,
but the risk is so low it's very hard to calculate." Resource:

Defenders
of the use of DU in armaments claim, perhaps truthfully, that the
alpha radiation emitted by the Uranium238 doesn’t
go far enough to do damage to living organisms (mainly, people).
However, radiation does not have far to travel when the U238 has been inhaled and lodges permanently in the lungs. Presumably,
ingested DU does not accumulate, and passes from the body in a
short period of time, limiting exposure. How it could be ingested
without being inhaled is a question for research.

Each DU round fired by U.S. M-1 series tanks creates as much as 3,100
grams of ultra-fine radioactive/heavy metal dust upon impact, which
is insoluble, easily inhaled, and may remain in the body for years,
gradually going from the lungs into other organs and skeletal
structures. This is by far the most serious form of exposure.
This is also the least studied type of exposure among military
scientists.

Here
is what the National Institutes of Health said about
depleted uranium:

“During
the Gulf War, several military regulations required that soldiers’
medical records should be noted if they entered areas known or
suspected to be contaminated by radioactive materials, and that
those soldiers should be provided medical tests to determine the
level of exposure, if any. The DOD failed to follow the law, and
there no known records of the length or level of DU exposures. As
with other Gulf War exposures, the lack of reliable data remains a
serious obstacle to researchers investigating DU poisoning.”

In
1999, the VA launched a DU testing program, and veterans who
believe they may have been exposed should call the VA at (800)
PGW-VETS (800-749-8387): Veterans’ Special Issues Helpline)
or the DOD at (800) 472-6719 for
further information. If the VA or DOD do not respond to your call
within one week, write a letter to
your military commander or your local VA Medical Center and request
the DU test. Although testing results for the presence of DU in
urine may be ineffective after so many years, the NGWRC strongly
encourages participation in this testing program.

Part
of DU testing involves a lengthy questionnaire, and the results of
the questionnaire may force the VA or DOD to presume you were
exposed, even if the test results are negative. Many soldiers were
never informed that the shrapnel in their bodies was DU.

Status
of Investigations and Epidemiological Research – DU
exists in large quantities and its use in munitions relieves
governments of their fiscal and legal responsibilities to properly
store it.i In addition, DU’s
extreme density (1.7 times that of lead), pyrophoricity (it burns
when it fragments), and resistance to deformation (when alloyed
with a small amount of titanium) enable it to effectively penetrate
tank armor.ii The US Navy is, however, phasing out its use of small caliber DU
rounds (20mm). It continues to be used in the present Iraqi and
Afghanistan Wars.

Collect,
handle, or participate in cleaning up spent DU fragments or
penetrators.

Breathe
smoke or dust from a fire involving DU armor and/or rounds, such
as the July 1991 fire at Doha, Kuwait.

Treat
those injured by DU shrapnel or covered with DU dust; and

Maintain
or repair vehicles struck by DU rounds.

Recently
published and/or released information from the Armed Forces
Radiobiology Research Institute (part of the DOD), plus findings
from a VA follow-up program at the Baltimore, Maryland VA, show
evidence that:

Laboratory
studies on rats indicate short-term effects include kidney damage,
while long-term effects may include cancer, central nervous system
problems, immune system disorders and reproductive effects.iii

Few
humans exposed to DU have been studied, therefore little is known
about the effects DU has had or may have in the future on exposed
populations. The US government claims it has not found evidence of
significant health effects caused by DU in a study of a few dozen
Gulf War veterans,iv although Pentagon spokesmen have lied about the existence of cancer
among these veterans.v There have been many claims
made about DU causing a large number of serious health effects in
Iraq, the Balkans, and Afghanistan, but these claims have not been
confirmed by credible, independent sources.

DU
may also contaminate soil, water, and air, as well as plant and
animal life. The extent of the contamination and its risk to
public health depend on the quantity and size of the DU released
its local concentration, and environmental conditions.

The
use of DU munitions by the US and its allies in the war in
Afghanistan remains unclear. Claims about the use of DU munitions
in Afghanistan have neither been confirmed by the US military, nor
verified by independent investigations. Nonetheless, it appears
likely that US forces used some DU munitions, and the Taliban
and/or al Qaeda may have possessed DU rounds.vi, vii, viii, ix, x, xi, xii, xiii.

Many
developments have occurred since publication of the initial version
of this Guide. Most notable has been the issuance of a November
2008 report by the VA’s “Research Advisory Committee
on Gulf War Veteran’s Illnesses” which can be
viewed online at:

a.
On November 2, 1994, Congress enacted the “Persian Gulf War
Veterans’ Benefits Act,” Title I of the “Veterans’
Benefits Improvements Act of 1994,” Public
Law (PL) 103-446.

The
statute added a new section, 38 U.S.C. 1117, authorizing the
Department of Veterans Affairs (VA) to compensate any Gulf War (GW)
veteran suffering from a chronic disability resulting from an
undiagnosed illness or combination of undiagnosed illnesses which
manifested either during active duty in the Southwest Asia theater
of operations during the GW, or to a degree of 10 percent more
within a presumptive period following service in the Southwest Asia
theater of operations during the GW

b.
The “Persian
Gulf War Veterans’ Act of 1998,” PL
105-277,
authorized VA to compensate GW veterans for diagnosed or
undiagnosed disabilities that are determined by VA regulation to
warrant a presumption of service connection based on a positive
association with exposure to one of the following as a result of GW
service:

a
toxic agent

an
environmental or wartime hazard, or

a
preventive medication or vaccine

Note:
This statute added 38 U.S.C. 1118.

c.
The “Veterans
Education and Benefits Expansion Act of 2001,” PL
107-103,
expanded the definition of “qualifying chronic disability”
under 38 U.S.C. 1117 to include, effective March 1, 2002, not only
a disability resulting from an undiagnosed illness but also

a
medically unexplained chronic multi-symptom illness that is
defined by a cluster of signs and symptoms, and

any
diagnosed illness that is determined by VA regulation to warrant
presumption of service connection

a
broad, but non-exclusive, list of signs and symptoms which may be
representative of undiagnosed or chronic, multi-symptom illnesses
for which compensation may be paid,

and
the presumptive period for service connection

Qualifying
chronic disability, under
38 CFR 3.317, means a chronic disability resulting from any of the
following or any combination of the following:

an
undiagnosed illness

a
medically unexplained chronic multi-symptom illness, such as
chronic fatigue syndrome, fibromyalgia, and irritable bowel
syndrome, that is defined by a cluster of signs or symptoms,(there
are some rule changes that will help the veterans in this area)
and/or

any
diagnosed illness that is determined by VA regulation to warrant a
presumption of service connection

The
presumptive period for manifestation of qualifying chronic
disability under 38 CFR 3.317

begins
on the date following last performance of active military, naval,
or air service in the Southwest Asia theater of operations during
the GW,

and
extends through December 31, 2011 (There
is movement to change this)

38
CFR 3.317 specifies the following 13 categories of signs or
symptoms that may represent a qualifying chronic disability:

abnormal
weight loss

cardiovascular
signs or symptoms

fatigue

gastrointestinal
signs or symptoms

headache

joint
pain

menstrual
disorders

muscle
pain

neurologic
signs or symptoms

neuropsychological
signs or symptoms

signs
or symptoms involving the skin

signs
or symptoms involving the upper and lower respiratory system, and

sleep
disturbances

Notes:

The
list of 13 illness categories is not exclusive.

Signs
or symptoms not represented by one of the listed categories may
also qualify for consideration under 38 CFR 3.317.

A
disability that is affirmatively shown to have resulted from a
cause other than GW service may not be compensated under 38 CFR
3.317.

To
qualify, the claimed disability must be chronic, that is, it must have
persisted for a period of six months or more.

Measure
the six-month period of chronicity from the earliest date on which
all pertinent evidence establishes that the signs or symptoms of
the disability first became manifest.

Note:
If a disability is subject to intermittent episodes of improvement
and worsening within a six-month period, consider the disability to
be chronic.

d.
In July of 2010 a letter was sent to all of the adjudicators with a
revisions to 38 C.F.R. § 3.317 to clarify the Meaning of
“Medically Unexplained Chronic Multisystem Illness”
Related to Gulf War and Southwest Asia Service. VA is revising §
3.317 to clarify that the three listed diagnosed multisymptom
illnesses are not exclusive, but rather are examples that can serve
to inform VA medical examiners and adjudicators of the general
types of medically unexplained chronic multisymptom illnesses that
may qualify for service connection under the § 1117 authority.

This
was one of the changes that was briefed in an RAC meeting by the
Department of Veterans Affairs Chief of Staff.

Appendix
IV - Researchers

a.
Lea Steele - The
Kansas Commission on Veterans Affairs completed the first
state-sponsored study of Gulf War Illnesses in 2000. The VA‟s
RAC interim report in 2004 conclusions study agreed with the Kansas
study; that Gulf War Illnesses is a major health problem for
veterans who deployed to the theater. The Kansas study identified
six types of symptom groups associated with Gulf War service:

A. Neurological
(memory, headache, mood, dizziness problems)

B. Fatigue and
sleep disorders

C. Pain in joints
and muscles

D.
Gastrointestinal (diarrhea and nausea)

E. Respiratory
(persistent cough and wheezing)

F. Skin
(rashes and other problems)

This
random telephone study of Kansas Gulf War veterans, which was
published in the November 15, 2000 issues of The
American Journal of Epidemiology,
noted that deployed Gulf-era veterans were two to five times more
likely to report having the above symptoms compared to non-deployed
veterans. The tendency of deployed veterans to have multiple
symptoms (3-6) on a chronic basis was referred to as “Gulf
War Illness.” The Kansas study also showed difference in
symptom severity based on branch of service, time in theater, and
specific in-theater locations. Additionally, this research
demonstrated that health problems from vaccines existed even in
those who did not deploy – important information for
later-serving service members.

The Kansas Study
has since been done by many other researchers. All reached the
same finding.

b.
Dr. Robert Haley -
Dr. Haley and colleagues at the University of Texas Southwestern
have been conducting epidemiologic, clinical and laboratory
research on the “Gulf War Syndrome” and related
neurological illnesses in Gulf War veterans since March 1994. The
work has been supported by a continuing grant from the Perot
Foundation until a contract was done with the VA. In 2009 the VA
terminated the contract. The objectives of the research are to
define new or unique clinical syndromes among Gulf War veterans,
determine their causes, identify areas of damage or dysfunction in
the brain and nervous system responsible for the symptoms, develop
a cost-effective battery of clinical tests that can diagnose the illness, search for underlying genetic traits that
might predispose to the illness, and perform clinical trials of
promising treatments.

The
initial studies identified three primary syndromes in a Naval
Reserve construction battalion (Seabees) that appear to be unique,
demonstrated that the syndromes are associated with subtle
dysfunction of the brainstem and lower parts of the brain, and
found epidemiologic associations between the syndromes and risk
factors of exposure to combinations of chemicals in the Gulf War.

Genetic
studies have identified a genetic trait (PON1 enzymes) that may
explain why some soldiers sustained brain damage from exposure to
neurotoxic chemicals while others working alongside them remained
well. Most recently, research using magnetic resonance spectroscopy
has demonstrated a loss of functioning brain cells in deep brain
structures of ill Gulf War veterans. Additional commentaries by Dr.
Haley have challenged the government‟s stress theory of Gulf
War syndrome and findings of no difference in morality,
hospitalization and birth defects between Gulf War-deployed and
nondeployed military populations, Additional research and
publications are in process.

(1)
Except as provided in paragraph (a)(7) of this section, VA will pay
compensation in accordance with chapter 11 of title 38, United
States Code, to a Persian Gulf veteran who exhibits objective
indications of a qualifying chronic disability, provided that such
disability:

(i)
Became manifest either during active military, naval, or air
service in the Southwest Asia theater of operations, or to a degree
of 10 percent or more not later than December 31, 2016; and

(ii)
By history, physical examination, and laboratory tests cannot be
attributed to any known clinical diagnosis.

(2) (i)
For purposes of this section, a qualifying
chronic disability means a chronic disability resulting from any of the following (or
any combination of the following):

(A)
An undiagnosed illness;

(B)
A medically unexplained chronic multisymptom illness that is
defined by a cluster of signs or symptoms, such as:

Note
to paragraph (a)(2)(i)(B)(3):
Functional
gastrointestinal disorders are a group of conditions characterized
by chronic or recurrent symptoms that are unexplained by any
structural, endoscopic, laboratory, or other objective signs of
injury or disease and may be related to any part of the
gastrointestinal tract. Specific functional gastrointestinal
disorders include, but are not limited to, irritable bowel
syndrome, functional dyspepsia, functional vomiting, functional
constipation, functional bloating, functional abdominal pain
syndrome, and functional dysphagia. These disorders are commonly
characterized by symptoms including abdominal pain, substernal
burning or pain, nausea, vomiting, altered bowel habits (including
diarrhea, constipation), indigestion, bloating, postprandial
fullness, and painful or difficult swallowing. Diagnosis of
specific functional gastrointestinal disorders is made in
accordance with established medical principles, which generally
require symptom onset at least 6 months prior to diagnosis and the
presence of symptoms sufficient to diagnose the specific disorder
at least 3 months prior to diagnosis.

(ii)
For purposes of this section, the term medically
unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or
etiology, that is characterized by overlapping symptoms and signs
and has features such as fatigue, pain, disability out of
proportion to physical findings, and inconsistent demonstration of
laboratory abnormalities. Chronic multisymptom
illnesses of partially understood etiology and
pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained.

(3)
For purposes of this section, “objective indications of
chronic disability” include both “signs,” in the
medical sense of objective evidence perceptible to an examining
physician, and other, non-medical indicators that are capable of
independent verification.

(4)
For purposes of this section, disabilities that have existed for 6
months or more and disabilities that exhibit intermittent episodes
of improvement and worsening over a 6-month period will be
considered chronic. The 6-month period of chronicity will be
measured from the earliest date on which the pertinent evidence
establishes that the signs or symptoms of the disability first
became manifest.

(5)
A qualifying chronic disability referred to in this section shall
be rated using evaluation criteria from part 4 of this chapter for
a disease or injury in which the functions affected, anatomical
localization, or symptomatology are similar.

(6)
A qualifying chronic disability referred to in this section shall
be considered service connected for purposes of all laws of the
United States.

(7)
Compensation shall not be paid under this section for a chronic
disability:

(i)
If there is affirmative evidence that the disability was not
incurred during active military, naval, or air service in the
Southwest Asia theater of operations; or

(ii)
If there is affirmative evidence that the disability was caused by
a supervening condition or event that occurred between the
veteran’s most recent departure from active duty in the
Southwest Asia theater of operations and the onset of the
disability; or

(iii)
If there is affirmative evidence that the disability is the result
of the veteran’s own willful misconduct or the abuse of
alcohol or drugs.

(b) Signs
or symptoms of undiagnosed illness and medically unexplained
chronic multisymptom illnesses.
For the purposes of paragraph (a)(1) of this section, signs or
symptoms which may be manifestations of undiagnosed illness or
medically unexplained chronic multisymptom illness include, but are
not limited to:

(1)
Fatigue.

(2)
Signs or symptoms involving skin.

(3)
Headache.

(4)
Muscle pain.

(5)
Joint pain.

(6)
Neurological signs or symptoms.

(7)
Neuropsychological signs or symptoms.

(8)
Signs or symptoms involving the respiratory system (upper or
lower).

(9)
Sleep disturbances.

(10)
Gastrointestinal signs or symptoms.

(11)
Cardiovascular signs or symptoms.

(12)
Abnormal weight loss.

(13)
Menstrual disorders.

(c) Presumptive
service connection for infectious diseases.

(1)
Except as provided in paragraph (c)(4) of this section, a disease
listed in paragraph (c)(2) of this section will be service
connected if it becomes manifest in a veteran with a qualifying
period of service, provided the provisions of paragraph (c)(3) of
this section are also satisfied.

(2)
The diseases referred to in paragraph (c)(1) of this section are
the following:

(i)
Brucellosis.

(ii)
Campylobacter jejuni.

(iii)
Coxiella burnetii (Q fever).

(iv)
Malaria.

(v)
Mycobacterium tuberculosis.

(vi)
Nontyphoid Salmonella.

(vii)
Shigella.

(viii)
Visceral leishmaniasis.

(ix)
West Nile virus.

(3)
The diseases listed in paragraph (c)(2) of this section will be
considered to have been incurred in or aggravated by service under
the circumstances outlined in paragraphs (c)(3)(i) and (ii) of this
section even though there is no evidence of such disease during the
period of service.

(i)
With three exceptions, the disease must have become manifest to a
degree of 10 percent or more within 1 year from the date of
separation from a qualifying period of service as specified in
paragraph (c)(3)(ii) of this section. Malaria must have become
manifest to a degree of 10 percent or more within 1 year from the
date of separation from a qualifying period of service or at a time
when standard or accepted treatises indicate that the incubation
period commenced during a qualifying period of service. There is no
time limit for visceral leishmaniasis or tuberculosis to have
become manifest to a degree of 10 percent or more.

(ii)
For purposes of this paragraph (c), the term qualifying period of
service means a period of service meeting the requirements of
paragraph (e) of this section or a period of active military,
naval, or air service on or after September 19, 2001, in
Afghanistan.

(4)
A disease listed in paragraph (c)(2) of this section shall not be
presumed service connected:

(i)
If there is affirmative evidence that the disease was not incurred
during a qualifying period of service; or

(ii)
If there is affirmative evidence that the disease was caused by a
supervening condition or event that occurred between the veteran’s
most recent departure from a qualifying period of service and the
onset of the disease; or

(iii)
If there is affirmative evidence that the disease is the result of
the veteran’s own willful misconduct or the abuse of alcohol
or drugs.

(1)
A report of the Institute of Medicine of the National Academy of
Sciences has identified the following long-term health effects that
potentially are associated with the infectious diseases listed in
paragraph (c)(2) of this section. These health effects and diseases
are listed alphabetically and are not categorized by the level of
association stated in the National Academy of Sciences report (see
Table to §3.317). If a veteran who has or had an infectious
disease identified in column A also has a condition identified in
column B as potentially related to that infectious disease, VA must
determine, based on the evidence in each case, whether the column B
condition was caused by the infectious disease for purposes of
paying disability compensation. This does not preclude a finding
that other manifestations of disability or secondary conditions
were caused by an infectious disease.

(2)
If a veteran presumed service connected for one of the diseases
listed in paragraph (c)(2) of this section is diagnosed with one of
the diseases listed in column “B” in the table within
the time period specified for the disease in the same table, if a
time period is specified or, otherwise, at any time, VA will
request a medical opinion as to whether it is at least as likely as
not that the condition was caused by the veteran having had the
associated disease in column “A” in that same table.

(1)
The term Persian
Gulf veteran means a veteran who served on active military, naval, or air
service in the Southwest Asia theater of operations during the
Persian Gulf War.

(2)
The Southwest
Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq
and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman,
the Gulf of
Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red
Sea, and the airspace above these locations. (Authority: 38 U.S.C.
1117, 1118).

(a)
Except as provided in paragraph (b) of this section, the
development of amyotrophic lateral sclerosis manifested at any time
after discharge or release from active military, naval, or air
service is sufficient to establish service connection for that
disease.

(b)
Service connection will not be established under this section:

(1)
If there is affirmative evidence that amyotrophic lateral sclerosis
was not incurred during or aggravated by active military, naval, or
air service;

(2)
If there is affirmative evidence that amyotrophic lateral sclerosis
is due to the veteran’s own willful misconduct; or

(3)
If the veteran did not have active, continuous service of 90 days
or more. (Authority: 38 U.S.C. 501(a)(1))

(a)
General.
The basic considerations relating to service connection are stated
in §3.303. The criteria in this section apply only to
disabilities which may have resulted from service in a period of
war or service rendered on or after January 1, 1947.

(b)
Presumption of
soundness. The
veteran will be considered to have been in sound condition when
examined, accepted and enrolled for service except as to defects,
infirmities, or disorders noted at entrance into service, or where
clear and unmistakable (obvious or manifest) evidence demonstrates
that an injury or disease existed prior thereto and was not
aggravated by such service. Only such conditions as are recorded in
examination reports are to be considered as noted. (Authority: 38
U.S.C. 1111)

(1)
History of preservice existence of conditions recorded at the time
of examination does not constitute a notation of such conditions
but will be considered together with all other material evidence in
determinations as to inception. Determinations should not be based
on medical judgment alone as distinguished from accepted medical
principles, or on history alone without regard to clinical factors
pertinent to the basic character, origin and development of such
injury or disease. They should be based on thorough analysis of the
evidentiary showing and careful correlation of all material facts,
with due regard to accepted medical principles pertaining to the
history, manifestations, clinical course, and character of the
particular injury or disease or residuals thereof.

(2)
History conforming to accepted medical principles should be given
due consideration, in conjunction with basic clinical data, and be
accorded probative value consistent with accepted medical and
evidentiary principles in relation to value consistent with
accepted medical evidence relating to incurrence, symptoms and
course of the injury or disease, including official and other
records made prior to, during or subsequent to service, together
with all other lay and medical evidence concerning the inception,
development and manifestations of the particular condition will be
taken into full account.

(3)
Signed statements of veterans relating to the origin, or incurrence
of any disease or injury made in service if against his or her own
interest is of no force and effect if other data do not establish
the fact. Other evidence will be considered as though such
statement were not of record. (Authority: 10 U.S.C. 1219)

(c)
Development.
The development of evidence in connection with claims for service
connection will be accomplished when deemed necessary but it should
not be undertaken when evidence present is sufficient for this
determination. In initially rating disability of record at the time
of discharge, the records of the service department, including the
reports of examination at enlistment and the clinical records
during service, will ordinarily suffice. Rating of combat injuries
or other conditions which obviously had their inception in service
may be accomplished pending receipt of copy of the examination at
enlistment and all other service records.

(d)
Combat.
Satisfactory lay or other evidence that an injury or disease was
incurred or aggravated in combat will be accepted as sufficient
proof of service connection if the evidence is consistent with the
circumstances, conditions or hardships of such service even though
there is no official record of such incurrence or aggravation.
(Authority: 38 U.S.C. 1154(b))

(e)
Prisoners of war.
Where disability compensation is claimed by a former prisoner of
war, omission of history or findings from clinical records made
upon repatriation is not determinative of service connection,
particularly if evidence of comrades in support of the incurrence
of the disability during confinement is available. Special
attention will be given to any disability first reported after
discharge, especially if poorly defined and not obviously of
intercurrent origin. The circumstances attendant upon the
individual veteran’s confinement and the duration thereof
will be associated with pertinent medical principles in determining
whether disability manifested subsequent to service is
etiologically related to the prisoner of war experience.

(f) Posttraumatic
stress disorder.
Service connection for posttraumatic stress disorder requires
medical evidence diagnosing the condition in accordance with
§4.125(a) of this chapter; a link, established by medical
evidence, between current symptoms and an in-service stressor; and
credible supporting evidence that the claimed in-service stressor
occurred. The following provisions apply to claims for service
connection of posttraumatic stress disorder diagnosed during
service or based on the specified type of claimed stressor:

(1)
If the evidence establishes a diagnosis of posttraumatic stress
disorder during service and the claimed stressor is related to that
service, in the absence of clear and convincing evidence to the
contrary, and provided that the claimed stressor is consistent with
the circumstances, conditions, or hardships of the veteran’s
service, the veteran’s lay testimony alone may establish the
occurrence of the claimed in-service stressor.

(2)
If the evidence establishes that the veteran engaged in combat with
the enemy and the claimed stressor is related to that combat, in
the absence of clear and convincing evidence to the contrary, and
provided that the claimed stressor is consistent with the
circumstances, conditions, or hardships of the veteran’s
service, the veteran’s lay testimony alone may establish the
occurrence of the claimed in-service stressor.

(3)
If a stressor claimed by a veteran is related to the veteran’s
fear of hostile military or terrorist activity and a VA
psychiatrist or psychologist, or a psychiatrist or psychologist
with whom VA has contracted, confirms that the claimed stressor is
adequate to support a diagnosis of posttraumatic stress disorder
and that the veteran’s symptoms are related to the claimed
stressor, in the absence of clear and convincing evidence to the
contrary, and provided the claimed stressor is consistent with the
places, types, and circumstances of the veteran’s service,
the veteran’s lay testimony alone may establish the
occurrence of the claimed in-service stressor. For purposes of this
paragraph, “fear of hostile military or terrorist activity”
means that a veteran experienced, witnessed, or was confronted with
an event or circumstance that involved actual or threatened death
or serious injury, or a threat to the physical integrity of the
veteran or others, such as from an actual or potential improvised
explosive device; vehicle-imbedded explosive device; incoming
artillery, rocket, or mortar fire; grenade; small arms fire,
including suspected sniper fire; or attack upon friendly military
aircraft, and the veteran’s response to the event or
circumstance involved a psychological or psycho-

physiological
state of fear, helplessness, or horror.

(4)
If the evidence establishes that the veteran was a prisoner-of-war
under the provisions of §3.1(y) of this part and the claimed
stressor is related to that prisoner-of-war experience, in the
absence of clear and convincing evidence to the contrary, and
provided that the claimed stressor is consistent with the
circumstances, conditions, or hardships of the veteran’s
service, the veteran’s lay testimony alone may establish the
occurrence of the claimed in-service stressor.

(5)
If a posttraumatic stress disorder claim is based on in-service
personal assault, evidence from sources other than the veteran’s
service records may corroborate the veteran’s account of the
stressor incident. Examples of such evidence include, but are not
limited to: records from law enforcement authorities, rape crisis
centers, mental health counseling centers, hospitals, or
physicians; pregnancy tests or tests for sexually transmitted
diseases; and statements from family members, roommates, fellow
service members, or clergy. Evidence of behavior changes following
the claimed assault is one type of relevant evidence that may be
found in these sources. Examples of behavior changes that may
constitute credible evidence of the stressor include, but are not
limited to: a request for a transfer to another military duty
assignment; deterioration in work performance; substance abuse;
episodes of depression, panic attacks, or anxiety without an
identifiable cause; or unexplained economic or social behavior
changes. VA will not deny a posttraumatic stress disorder claim
that is based on in-service personal assault without first advising
the claimant that evidence from sources other than the veteran’s
service records or evidence of behavior changes may constitute
credible supporting evidence of the stressor and allowing him or
her the opportunity to furnish this type of evidence or advise VA
of potential sources of such evidence. VA may submit any evidence
that it receives to an appropriate medical or mental health
professional for an opinion as to whether it indicates that a
personal assault occurred. (Authority: 38 U.S.C. 501(a), 1154)

(a)
Chronic diseases. The
following diseases shall be granted service connection although not
otherwise established as incurred in or aggravated by service if
manifested to a compensable degree within the applicable time
limits under §3.307 following service in a period of war or
following peacetime service on or after January 1, 1947, provided
the rebuttable presumption provisions of §3.307 are also
satisfied.

Anemia,
primary.

Arteriosclerosis.

Arthritis.

Atrophy,
Progressive muscular.

Brain
hemorrhage.

Brain
thrombosis.

Bronchiectasis.

Calculi
of the kidney, bladder, or gallbladder.

Cardiovascular-renal disease,
including hypertension. (This term applies to combination
involvement of the type of arteriosclerosis, nephritis, and organic
heart disease, and since hypertension is an early symptom long
preceding the development of those diseases in their more obvious
forms, a disabling hypertension within the 1-year period will be
given the same benefit of service connection as any of the chronic
diseases listed.)

Cirrhosis
of the liver.

Coccidioidomycosis.

Diabetes
mellitus.

Encephalitis
lethargica residuals.

Endocarditis.
(This term covers all forms of valvular heart disease.)

Endocrinopathies.

Epilepsies.

Hansen’s
disease.

Hodgkin’s
disease.

Leukemia.

Lupus
erythematosus, systemic.

Myasthenia
gravis.

Myelitis.

Myocarditis.

Nephritis.

Other
organic diseases of the nervous system.

Osteitis
deformans (Paget’s disease).

Osteomalacia.

Palsy,
bulbar.

Paralysis
agitans.

Psychoses.

Purpura
idiopathic, hemorrhagic.

Raynaud’s
disease.

Sarcoidosis.

Scleroderma.

Sclerosis,
amyotrophic lateral.

Sclerosis,
multiple.

Syringomyelia.

Thromboangiitis
obliterans (Buerger’s disease).

Tuberculosis,
active.

Tumors,
malignant, or of the brain or spinal cord or peripheral nerves.

Ulcers, peptic (gastric or
duodenal) (A proper diagnosis of gastric or duodenal ulcer (peptic
ulcer) is to be considered established if it represents a medically
sound interpretation of sufficient clinical findings warranting
such diagnosis and provides an adequate basis for a differential
diagnosis from other conditions with like symptomatology; in short,
where the preponderance of evidence indicates gastric or duodenal
ulcer (peptic ulcer). Whenever possible, of course, laboratory
findings should be used in corroboration of the clinical data.

(b)
Tropical diseases.
The following
diseases shall be granted service connection as a result of
tropical service, although not otherwise established as incurred in
service if manifested to a compensable degree within the applicable
time limits under §3.307 or §3.308 following service in a
period of war or following peacetime service provided the
rebuttable presumption provisions of §3.307 are also
satisfied.

Amebiasis.

Blackwater
fever.

Cholera.

Dracontiasis.

Dysentery.

Filariasis.

Leishmaniasis,
including kala-azar.

Loiasis.

Malaria.

Onchocerciasis.

Oroya
fever.

Pinta.

Plague.

Schistosomiasis.

Yaws.

Yellow
fever.

Resultant
disorders or diseases originating because of therapy administered
in connec­tion with such diseases or as a preventative thereof.

(c) Diseases
specific as to former prisoners of war.

(1)
If a veteran is a former prisoner of war, the following diseases
shall be service connected if manifest to a degree of disability of
10 percent or more at any time after discharge or release from
active military, naval, or air service even though there is no
record of such disease during service, provided the rebuttable
presumption provisions of §3.307 are also satisfied.

Psychosis.

Any
of the anxiety states.

Dysthymic
disorder (or depressive neurosis).

Organic
residuals of frostbite, if it is determined that the veteran was
interned in climatic conditions consistent with the occurrence of
frostbite.

On
or after October 10, 2008, Osteoporosis, if the Secretary
determines that the veteran has posttraumatic stress disorder
(PTSD).

(2)
If the veteran:

(i)
Is a former prisoner of war and;

(ii)
Was interned or detained for not less than 30 days, the following
diseases shall be service connected if manifest to a degree of 10
percent or more at any time after discharge or release from active
military, naval, or air service even though there is no record of
such disease during service, provided the rebuttable presumption
provisions of §3.307 are also satisfied.

On or after
September 28, 2009, Osteoporosis. (Authority: 38 U.S.C. 501(a) and
1112(b))

(d) Diseases
specific to radiation-exposed veterans.

(1)The diseases listed
in paragraph (d)(2) of this section shall be service-connected if
they become manifest in a radiation-exposed veteran as defined in
paragraph (d)(3) of this section, provided the rebuttable
presumption provisions of §3.307 of this part are also
satisfied.

(2)
The diseases referred to in paragraph (d)(1) of this section are
the following:

Note:
For the purposes of this section, the term urinary
tract means the
kidneys, renal pelves, ureters, urinary bladder, and urethra.
(Authority: 38 U.S.C. 1112(c)(2))

(3)
For purposes of this section:

(i)
The term radiation-exposed
veteran means either
a veteran who, while serving on active duty, or an individual who
while a member of a reserve component of the Armed Forces during a
period of active duty for training or inactive duty training,
participated in a radiation-risk activity.

(ii)
The term radiation-risk
activity means:

(A)
Onsite participation in a test involving the atmospheric detonation
of a nuclear device.

(B)
The occupation of Hiroshima or Nagasaki, Japan, by United States
forces during the period beginning on August 6, 1945, and ending on
July 1, 1946.

(C)
Internment as a prisoner of war in Japan (or service on active duty
in Japan immediately following such internment) during World War II
which resulted in an opportunity for exposure to ionizing radiation
comparable to that of the United States occupation forces in
Hiroshima or Nagasaki, Japan, during the period beginning on August
6, 1945, and ending on July 1, 1946.

(D) (1)
Service in which the service member was, as part of his or her
official military duties, present during a total of at least 250
days before February 1, 1992, on the grounds of a gaseous diffusion
plant located in Paducah, Kentucky, Portsmouth, Ohio, or the area
identified as K25 at Oak Ridge, Tennessee, if, during such service
the veteran:

(i)
Was monitored for each of the 250 days of such service through the
use of dosimetry badges for exposure at the plant of the external
parts of veteran’s body to radiation; or

(ii)
Served for each of the 250 days of such service in a position that
had exposures comparable to a job that is or was monitored through
the use of dosimetry badges; or

(2)
Service before January 1, 1974, on Amchitka Island, Alaska, if,
during such service, the veteran was exposed to ionizing radiation
in the performance of duty related to the Long Shot, Milrow, or
Cannikin underground nuclear tests.

(3)
For purposes of paragraph (d)(3)(ii)(D)(1)
of this section, the term “day” refers to all or any
portion of a calendar day.

(E)
Service in a capacity which, if performed as an employee of the
Department of Energy, would qualify the individual for inclusion as
a member of the Special Exposure Cohort under section 3621(14) of
the Energy Employees Occupational Illness Compensation Program Act
of 2000 (42 U.S.C. 7384l(14)).

(iii)
The term atmospheric
detonation includes
underwater nuclear detonations.

(iv)
The term onsite
participation means:

(A)
During the official operational period of an atmospheric nuclear
test, presence at the test site, or performance of official
military duties in connection with ships, aircraft or other
equipment used in direct support of the nuclear test.

(B)
During the six month period following the official operational
period of an atmospheric nuclear test, presence at the test site or
other test staging area to perform official military duties in
connection with completion of projects related to the nuclear test
including decontamination of equipment used during the nuclear
test.

(C)
Service as a member of the garrison or maintenance forces on
Eniwetok during the periods June 21, 1951, through July 1, 1952,
August 7, 1956, through August 7, 1957, or November 1, 1958,
through April 30, 1959.

(D)
Assignment to official military duties at Naval Shipyards involving
the decontamination of ships that participated in Operation
Crossroads.

(v)
For tests conducted by the United States, the term operational
period means:

(A) For Operation TRINITY
the period July 16,
1945 through August 6, 1945.

(B) For Operation CROSSROADS
the period July 1,
1946 through August 31, 1946.

(C) For Operation SANDSTONE
the period April 15,
1948 through May 20, 1948.

(D) For Operation RANGER
the period January
27, 1951 through February 6, 1951.

(E) For Operation GREENHOUSE
the period April 8,
1951 through June 20, 1951.

(F) For Operation BUSTER-JANGLE
the period October
22, 1951 through December 20, 1951

(G) For Operation
TUMBLER-SNAPPER the
period April 1, 1952 through June 20, 1952.

(H) For Operation IVY
the period November 1, 1952 through December 31, 1952.

(I) For Operation
UPSHOT-KNOTHOLE the
period March 17, 1953 through June 20, 1953.

(J) For Operation CASTLE
the period March 1,
1954 through May 31, 1954.

(K) For Operation TEAPOT
the period February
18, 1955 through June 10, 1955.

(L) For Operation WIGWAM
the period May 14,
1955 through May 15, 1955.

(M) For Operation REDWING
the period May 5,
1956 through August 6, 1956.

(N) For Operation PLUMBBOB
the period May 28,
1957 through October 22, 1957.

(O) For Operation HARDTACK
I the period April
28, 1958 through October 31, 1958.

(P) For Operation ARGUS
the period August
27, 1958 through September 10, 1958.

(Q) For Operation HARDTACK
II the period
September 19, 1958 through October 31, 1958.

(R) For Operation DOMINIC
I the period April
25, 1962 through December 31, 1962.

(S) For Operation DOMINIC
II/ PLOWSHARE the
period July 6, 1962 through August 15, 1962.

(vi)
The term occupation
of Hiroshima or Nagasaki, Japan, by United States forces
means official military duties within 10 miles of the city limits
of either Hiroshima or Nagasaki, Japan, which were required to
perform or support military occupation functions such as occupation
of territory, control of the population, stabilization of the
government, demilitarization of the Japanese military,
rehabilitation of the infrastructure or deactivation and conversion
of war plants or materials.

(vii)
Former prisoners of war who had an opportunity for exposure to
ionizing radiation comparable to that of veterans who participated
in the occupation of Hiroshima or Nagasaki, Japan, by United States
forces shall include those who, at any time during the period
August 6, 1945, through July 1, 1946:

(A) Were interned within 75
miles of the city limits of Hiroshima or within 150 miles of the
city limits of Nagasaki, or

(B) Can affirmatively show they
worked within the areas set forth in paragraph (d)(3)(vii)(A) of
this section although not interned within those areas, or

(C) Served immediately
following internment in a capacity which satisfies the definition
in paragraph (d)(3)(vi) of this section, or

(e)
Disease associated
with exposure to certain herbicide agents.
If a veteran was exposed to an herbicide agent during active
military, naval, or air service, the following diseases shall be
service-connected if the requirements of §3.307(a)(6) are met
even though there is no record of such disease during
service, provided further that the rebuttable presumption
provisions of §3.307(d) are also satisfied.

Note 2:
For purposes of this section, the term acute and subacute
peripheral neuropathy means transient peripheral neuropathy that
appears within weeks or months of exposure to an herbicide agent
and resolves within two years of the date of onset.

Note
3: For purposes of this section, the term ischemic heart disease does
not include hypertension or peripheral manifestations of
arteriosclerosis such as peripheral vascular disease or stroke, or
any other condition that does not qualify within the generally
accepted medical definition of Ischemic heart disease.

vSee Dan Fahey, “Depleted Legitimacy: The U.S. Study of
Gulf War Veterans Exposed to Depleted Uranium,” 4 May 2002,
http://www.ngwrc.org/conf2002/NGWRC-DU-Atlanta.pdf.

vi The reported dates of A-10 attacks are March 3-6, May 21, August 25,
September 20, November 15, and December 20, 2002, and February 12,
2003. U.S. Department of Defense News Transcript, “DOD News
Briefing – ASD PA Clarke and Brig. Gen. Rosa,” (5 March
2002). Evan Thomas, “‘Leave No Man Behind,’” Newsweek (18 March 2002) 26; Thom Shanker, “U.S. tells
how rescue turned into fatal firefight,” The New York Times (6 March 2002) A1; Peter Baker, “Afghans Strengthen U.S.
Force,” The Washington Post (8 March 2002) A1. Eric
Schmitt, “American Planes Foil an Attack on an Airfield in
Afghanistan,” The New York Times (22 May 2002) A9.
Cesar G. Soriano, “U.S. to stay in Afghanistan indefinitely,” USA Today (25 August 2002). Associated Press, “U.S.
base in Afghanistan attacked,” (20 September 2002).
Associated Press, “U.S. Bases Under Fire,” (15 November
2002). Eric Schmitt, “Paratrooper from New Jersey dies in
Afghan firefight near Pakistan border,” The New York Times (22 December 2002). Carlotta Gall, “Afghans report 17
civilian deaths in US-led bombing,” The New York Times (12 February 2003).

xi The figure of 1,000 tons of DU is based on completely
unsubstantiated claims about the quantity of DU contained in various
missiles and bombs. For example, this figure is based on an
assumption that Tomahawk cruise missiles, which have a total
in-flight weight of 2,900 lbs, contain 1,000 pounds of DU in
addition to a 1,000 high explosive warhead, the guidance system,
fuel, rocket engine, outer shell, wings, and other components. This
is not only highly improbable, but unsubstantiated: the proponents
of this claim offer no evidence to support their estimates on
quantities of DU in missiles and bombs.